AUTHORIZATION TO OBTAIN OR RELEASE RECORDS OR INFORMATION

Client's Name: *

Date of Birth * +

Social Security #: *

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

Name: *

Phone/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 Other

Please call Dr. Teimoori Please call Dr. Teimoori

This authorization will be in effect from: * +

To: * +

I understand that, with a few limited exceptions, my therapist may not obtain or release records and/or information about myself or my child unless I agree to the request. I understand that I give my permission for the records and/or information to be obtained or released only for the time period shown above. I may withdraw my consent at any time in writing, or if I am physically unable to write, by orally advising the therapist, who will duly note the date and time of the conversation.

Client Signature *

clear

Age: *

Date Signed * +

Client's Parent Signature: *

clear

Age: *

Date Signed * +

Therapist's Signature

clear