Name: __________________________________________

Address: ________________________________________

__________________________________________________

Dear Eileen Stein, MSSW, LICSW

I understand that you are required by law to keep case notes/records for my therapy/counseling while in your care. I request that you do not keep written or verbal notes more than required by law.

I understand you are required by law to keep the following records:

• Name and Address
• Dates of Service
• Fee for Service
• A signed “Disclosure Statement”

Thank You,

_________________________________/_____________

Signed Date