Request for Records Form - Mental Health & Developmental Services

My Information

Information about the person making the request.

Preferred name

Previous last name (if applicable)

Date of Birth*

Full Address

Contact Information

Daytime Telephone Number*

Alternate Telephone Number

Email address that will be used to communicate about this request*

Request Details

Their legal name

Their Date of Birth

My relationship to them is:

If this person is your child, please detail any custody / access agreements or orders that are in place:

Depending on your child’s age, or your custody and access we may need additional consents completed to provide you with this information.

Reason for request

This section is optional. But the information will assist staff in ensuring we provide you with everything you need (e.g. if it’s for a court matter or for an application for service).

Request Start Date

Request End Date

Up to and including this date

Specific Record Request Information

List them by name and include date if known.

Please add any details about types of records in this box:

In order to complete a full search, we require additional information about you/your relationships (if available) for those requesting information of a child:

Mother's Date of Birth

Father's Date of Birth

For those requesting information as a parent:

Child 1: Date of Birth

Child 2: Date of Birth

For additional children, kindly list their information here:

All Requestors:

Please attach photocopies of two pieces of identification (both sides), at least one of which shows your signature and at least one of which confirms your current mailing address – or you will be asked to show ID at the time of pick-up

Drop files here or

No file chosenAccepted file types: jpg, gif, png, pdf, Max. file size: 300 MB, Max. files: 4.

Request for Records Form – Mental Health & Developmental Services

Sections marked with an asterisk (*) must be completed for your request to be processed.