Consent

If using Employee Assistance Program please provide EAP authorization number, name of EAP, number of sessions. 

If using insurance please send images of both sides of your insurance card. 

Easy way to sign consent is take a picture of it then sign on screen surface take a picture of that and send back. If not copy, scan, sign an email. Hard copy can be mailed. 

Teletherapy Consent Form

I. Teletherapy is the delivery of psychological treatment and consultation provided through interactive internet technologies where the patient and the clinician are not in the same physical location.

II. Clients are expected to attend therapy sessions regularly and require a min 24 hours notice for cancellation and reschedule.

III. A lack of access to the information that might be achieved in a face to face visit but not in a teletherapy session may result in errors in psychological judgment.

IV. There might be a risk of deficiencies, delays or failures during the transfer of services due to electronic circumstances. 

V. Teletherapy does not provide emergency service.

VI. All information provided will be held confidential and will not be disclosed without permission, except where disclosure is required by law. The electronic systems that are used throughout the service incorporate network and software security protocols (encryption) in order to protect the confidentiality of the patient information and data. 

By signing below you acknowledge that:

You have fully understand and accept the terms mentioned above

You authorize the release of any medical or other information necessary to process insurance claims.

You agree to pay any co-pay and/or deductible the insurance does not pay. 

Date of Birth

Home address the insurance has for you on record

Name

First Name

Last Name

Date

Signature

Please only respond with any confidential information except appointment communications to susan@susanrazavi.com which is encrypted to protect your privacy.

%d bloggers like this: