Authorization Form

Client's Name

Date of Birth +

Social Security Number

I hereby give permission for Dr. Sahar Teimoori to obtain or release copies of the medical and psychological records to and/or speak with

Name

Telephone Number

Services provided from ________ to _________

I understand that these records and/or information will be used only for the purpose of

Helping me in therapy

Legal proceedings

Other

This authorization will be in effect from _______________ to ________________

Client Signature

clear

Age

Date Signed +

Client's Parent Signature

clear

Age

Date Signed +

Therapist's Signature

clear