The form below is to be used by Utah Valley Counseling clients and guardians (for clients who are minors) to request the following:

  • releasing patient records to self for use in medical, educational, work or employment settings
  • releasing patient records to a third party or agreeing to written or verbal communication about patient records between your therapist and/or the main office and a third party

Please consult with your therapist or office staff if you have questions about filling out this form.