Intake Forms

CAMARILLO OR WESTWOOD OFFICE:

Please click here to download a pdf of the intake form.

To make a payment with "Credit Card" please go to www.ProfessionalCharges.com and click on the "Make a Payment" button and complete the payment form. Start by entering my license number exactly like this format: LMFT-108725 . You will receive an email notification of the payment, and the payment will be automatically posted to your account.

Other types of payment:

You can make a payment with your personal Check to the order of: Mehrzad Bazyar; or simply pay cash.