Client Info and Participation Agreement

GENERAL SESSION

Janene Verabian provides the following services:

Independent Practitioner Newport Beach, CA

This information will be used to aid in serving you as a client. Please answer the following questions honestly and please understand that a yes or no answer to a particular question does not mean you cannot receive services from this practitioner. You honest answers will ensure you provide the appropriate care and service. All information provided will be under complete confidentiality within the Health Insurance Portability and Accountability Act (HIPAA) regulations.