This form is needed when you want to allow someone else to receive information about you. 

Common examples are:

  • If you are 18 years old or over and your parent wants to pay for therapy, you would need to complete this form to allow us to release your information to your parent.

  • If you have a 3rd party who is paying for therapy, you would need to give billing access to that 3rd party.

    • *If a 3rd party is paying for therapy, a 3rd Party Payer form is required.  Please call our office at 816-781-2349 and we will send the proper form to the 3rd party directly.

  • If there is a 3rd party, such as a caseworker, attorney, probation officer, school, relative or other individual, who you would like information released to, this form will be needed.

This form is also used to request a copy of your records or to request the therapist to write a letter or report for you. 


If you are requesting records, there is a $25 fee due prior to us releasing your records.  


If you request your therapist to write a letter or report, there is a $50 fee due prior to the therapist writing the requested letter/report.

This is the complete PDF of our Privacy Practices if you would like to review that.

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