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Dr. Zibaie cannot and will not disclose your case information without your written permission, except
under specific conditions outlined below:

1. If you threaten to harm yourself or someone else, Dr. Zibaie is obligated under federal and international
law to take whatever actions seem necessary to protect the safety of the person involved. This may include
divulging confidential information to others, including the police department.

2. If Dr. Zibaie have reason to believe that you or someone you know is abusing or neglecting a child or
that you, as the child, are being abused, he is obligated by law to report the abuse to the local Social
Services Department. In a similar manner, abuse of elders or dependent adults must be reported.

3. If a court of law issues a subpoena for your counseling records, this information may need to be
released. However, every attempt will be made by Dr. Zibaie’s legal council to protect your records by
invoking the therapist/client privilege.

4. If you direct Dr. Zibaie to tell someone else, he will always get an exchange of information consent
form signed by you. If you are taking medication prescribed for emotional or mental conditions he requires
a signed exchange of information consent from your prescribing physician.

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