Consent

Consent and insurance

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

Easy way to sign consent is take a screenshot picture of it then sign on screen with finger and send back. If not copy, scan, sign and return. Hard copy can be mailed. 

Teletherapy Consent Form

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

II. Clients are expected to attend therapy sessions as scheduled 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. 

VII. Please settle on a regular appointment time for the first four weeks. Any kind of change is difficult but it is even more challenging if you are unable to attend.

VIII. In therapy sometimes there may not be a good fit. Provider platforms and clinics are listed with types of insurance accepted on the homepage of https://susanrazavitherapist.com/

Suicide Prevention Hotline 212) 673-3000

Last Name

Emergency contact

Name of previous provider

Prescriber name and contact info. Doseage and name of prescription(s).

Date

Signature

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