Forms

Please download, print and complete the first five forms and e-mail them to Bijan@BijanAmirshahi.com before our first meeting. The sixth form is for you to read and keep. If more than one person, please have a set completed for each.  Thanks.

1- Informed Consent

2- Client Personal History

3- TELEHEALTH CONSENT FORM

4- No Secrets Policy – BA

5- HIPPA Notice Receipt

6- HIPPA Notice of Privacy Practices

7- Authorization to Release Confidential Information

8- Authorization to Exchange Confidential Information

 

 

Bijan Amirshahi 

Licensed Marriage and Family Therapist Lic. # 46183 

Licensed Professional Clinical Counselor Lic. # 387 

4000 Barranca Parkway, Suite 250 

Irvine, CA 92604 

Non-emergency Texts Only (949) 533-3177 

bijan@bijanamirshahi.com 

www.bijanamirshahi.com