Please let us know your name, dates of service, and the name of the professional at the MidAmerican Psychological Institute who assisted you. Please include the name of the professionals who will be receiving this information, and all of their contact information. Please be as detailed as possible in the comments section about why you need this information.

  • This field is for validation purposes and should be left unchanged.

Due to confidentiality concerns, and HIPPA compliance, this process will require significant paperwork to be completed to protect your Personal Health Information.

Many requests will also require a service fee.