Please download, print and complete the first three forms and bring to the first meeting. The fourth form is for you to read and keep. If more than one person, please have a set completed for each. In case a person under the age of 18 is being treated complete and bring the fifth form to the first meeting. Thanks.
Notice of Privacy Practices – Receipt Acknowledgement
HIPPA Notice of Privacy Practices
Authorization to Release Confidential Information
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 Tel. (949) 533-3177 bijan@bijanamirshahi.com www.bijanamirshahi.com
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