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.
Online privacy practices for susanrazavitherapist.com
ONLINE PRIVACY POLICY AGREEMENT June 6, 2024
susanrazavitherapist.com Privacy Policy will help you understand how we collect and use personal information from those who visit our website or make use of our online facilities and services, and what we will and will not do with the information we collect. Our Policy has been designed and created to assure those affiliated with susanrazavitherapist.com of our commitment and realization of our obligation not only to meet, but to exceed, most existing privacy standards.
We reserve the right to make changes to this Policy at any given time. If you have not registered with us and want to make sure that you are up to date with the latest changes, we advise you to frequently visit this page. If you are a registered user, we will notify you via email of any changes or updates made to this Policy. If at any point in time TrancePlan.com decides to make use of any personally identifiable information on file, in a manner vastly different from that which was stated when this information was initially collected, the user or users shall be promptly notified by email. Users at that time shall have the option as to whether to permit the use of their information in this separate manner.
This policy applies to https://susanrazavitherapist.com
are therelore consenting to the data collection procedures expressed in this Policy.
Please note that this Policy does not govern the collection and use of information by companies that susanrazavitherapist.com does not control, nor by individuals not employed or managed by us. If you visit a website that we mention or link to, be sure to review its privacy policy before providing the site with information. It is highly recommended and suggested that you review the privacy policies and conditions of any website you choose to use or frequent to better understand the way in which websites garner, make use of and share the information collected.
Specifically, this Policy will inform you of the following:
What personally identifiable information is collected from you through our website;
Why we collect personally identifiable information and the legal basis for such collection;
How we use the collected Information and with whom It may be shared.
What choices are available to you regarding the use of your data; and
The security procedures in place to protect the misuse of your information.
susanrazavitherapist.com may have the occasion to collect non-personal anonymous demographic information, such as age, gender, household income, political affiliation, race and religion, as well as the type of browser you are using, IP address, or type of operating system, which will assist us in providing and maintaining superior quality service.
Why We Collect Information and For How Long We are collecting your data for several reasons:
To better understand your needs and provide you with the services you have requested.
To fulfill our legitimate interest in improving our services and products.
To send you promotional emails containing information we think you may like when we have your consent to do so.
To contact you to fill out surveys or participate in other types of market research, when we had your consent to do so.
To customize our website, according to your online behavior and personal preferences.
The data we collect from you will be stored for no longer than necessary. The length of time we retain said information will be determined based upon the following criteria: the length of time your personal information remains relevant; the length of time it is reasonable to keep records to demonstrate that we have fulfilled our duties and obligations; any limitation periods within which claims might be made; any retention periods prescribed by law or recommended by regulators, professional bodies or associations; the type of contract we have with you, the existence of your consent, and our legitimate interest in keeping such information as stated in this Policy.
Use of Information Collected susanrazavitherapist.com does not now, nor will it in the future, sell, rent or lease any of its customer lists and/or names to any third parties. susanrazavitherapist.com may collect and may make use of personal information to assist in the operation of our website and to ensure delivery of the services you need and request. At times, we may find it necessary to use personally identifiable information as a means to keep you informed of other possible products and/or services that may be available to you from susanrazavitherapist.com
susanrazavitherapist.com may also be in contact with you with regards to completing surveys and/or research questionnaires related to your opinion of current, potential, or future services that may be offered. TrancePlan.com uses various third-party social media features including but not limited to Linkedin, Facebook, PsychologyToday.com and other interactive programs. These may collect your IP address and require cookies to work properly. These services are governed by the privacy policies of the providers and are not within susanrazavitherapist.com control.
Disclosure of Information susanrazavitherapist.com may not use or disclose the information provided by you except under the following circumstances:
Non-Marketing Purposes
As necessary to provide services or products you have ordered; in other ways described in this policy, or to which you have otherwise consented; in the aggregate with other information in such a way that your identity cannot reasonably be determined; as required by law or in response to a subpoena or search warrant; to outside auditors who have agreed to keep the information confidential; as necessary to enforce the terms of service on our website; as necessary to maintain, safeguard, and preserve all the rights and property of susanrazavitherapist.com
Non-Marketing Purposes susanrazavitherapist.com Greatly respects your privacy. We do maintain and preserve the right to contact you if needed by non-marketing purposes, such as bug alerts, security breach account issues, and changes in susanrazavitherapist.com products and services or changes in this policy. In certain circumstances, we may use our website, newspapers, or other public means to post a notice.
Children under the age of 13.
susanrazavitherapist.com website is not directed to, and does not knowingly collect personal identifiable information from, children under the age of 13. If it is determined that such information has been in advertently collected on anyone under the age of 13, we shall immediately take the necessary steps to ensure that information is deleted from our systems database or in the alternative that verifiable consent is obtained for the use and storage of such information .
Anyone under the age of 13 must seek and obtain parents or guardian permission to use this website.
Unsubscribe or opt out.
Determined based upon the following criteria: the length of time your personal information remains relevant; the length of time type of contract we have with you, the existence of your consent, and our legitimate interest in keeping such information as stated in this Policy.
Use of Information Collected susanrazavitherapist.com does not now, nor will it in the future, sell, rent or lease any of its customer lists and/or names to any third parties. susanrazavitherapist.com may collect and may make use of personal information to assist in the operation of our website and to ensure delivery of the services you need and request. At times, we may find it necessary to use personally identifiable information as a means to keep you informed of other possible products and/or services that may be available to you from https://susanrazavitherapist.com may also be in contact with you with regards to completing surveys and/or research questionnaires related to your opinion of current, potential, or future services that may be offered. susanrazavitherapist.com uses various third-party social media features including but not limited to Linkedin, Facebook, PsychologyToday.com and other interactive programs. These may collect your IP address and require cookies to work properly. These services are governed by the privacy policies of the providers and are not within susanrazavitherapist.com ‘s control. Disclosure of Information susanrazavitherapist.com may not use or disclose the information provided by you except under the following circumstances: Non-Marketing Purposes Children under the age of 13
susanrazavitherapist.com operations is not directed to and does not knowingly collect personal identifiable information from, children under the age of 13. it is determined that such information has been inadvertently collected on anyone under the age of 13, we shall necessarily take immediate steps to ensure that such information is deleted from our systems database, or in the alternative, that verb pliable parental consent is obtained for the us storage as such information. Anyone. under the age of then (13) must seek and obtain parent of guardan permission to use this website.
Unsubscribe or Opt-Out
All users and visitors to our website have the option to discontinue receiving communications from us by way of email or newsletters. To discontinue or unsubscribe from our website please send an email that you wish to unsubscribe to
susan@susanrazavi.com. If you wish to unsubscribe or opt out from any third-party websites, you must go to that specific website to unsubscribe or opt out. susanrazavitherapist.com Will continue to adhere to this policy with respect to any personal information previously collected.
Links to Other Websites
Our website does contain links to affiliate and other websites. TrancePlan.com does not claim nor accept responsibility for avare When they leave our webste and to read the pivacy statements of every website that collects personaly dentifable information. This Policy applies only and solely to the information collected by our website.
Notice to European Union users TrancePlan.com’s operations are located primarily in the United States. If you provide information to us, the information will be transferred out of the European Union (EU) and sent to the United States. (The adequacy decision on the EU-US Privacy became operational on August 1, 2016. This framework protects the fundamental rights of anyone in the EU whose personal data is transferred to the United States for commercial purposes. It allows the free transfer of data to companies that are certified in the US under the Privacy Shield.) By providing personal information to us, you are consenting to its storage and use as described in this Policy.
Your Rights as a Data Subject Under the regulations of the General Data Protection Regulation (“GDPR”) of the EU you have certain rights as a Data Subject. These rights are as follows: • The right to be informed: this means we must inform you of how we intend to use your personal data and we do this through the terms of this Policy. • The right of access: this means you have the right to request access to the data we hold about you and we must respond to those requests within one month. You can do this by sending an email to susan@susanrazavi.com. • The right to rectification: this means that if you believe some of the data we hold is incorrect, you have the right to have It corrected. You can do this by logging Into your account with us, or by sending us an emall with your request. You can do this by sending an email to susan@susanrazavi.com. • The right to erasure: this means you can request that the information we hold about you be deleted, and we will comply unless we have a compelling reason not to, in which case you will be informed of the reason. You can do this by sending an email to susan@susanrazavi.com.
For details regarding our security protections see the section below or visit our website at https://susanrazavitherapist.com Security
susanrazavitherapist.com takes precautions to protect your information.
When you submit sensitive information via the website, your information is protected both online and offline. Wherever we collect sensitive information (e.g. credit card information) that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a lock icon in the address bar. by looking for HTTPS at the beginning of the address of the webpage.
While using encryption to protect sensitive information and transmitted online, we also protect your information off-line. Only employees who need the information to perform a specific job for example, billing, or customer service, are granted access to personally identifiable information. The computers and servers, and which we store personally identified information Are kept in a secure environment. This is all done to prevent any loss, misuse, unauthorized, disclose your modification of the uses personally information under our control. The company also uses SLL secure socket layer for authentication and private communications to build users, trust and confidence in the Internet And website used by providing simple and secure access and communication of credit card and personal information.
Acceptance of terms.
By using this website, you are here by accepting the terms and conditions stipulated within this privacy policy agreement. If you are not in agreement with our terms and conditions, then you should reframe from further use of our sites. In addition, your continued use of our website, following proper notification, or in the posting of any updates or changes to our terms and conditions, show me that you agree, except such changes. the posting of any updates or changes.
How to Contact Us
If you have any questions or concerns regarding this privacy policy, as it relates to our website, please feel free to contact us at the following address. Email: susan@susanrazavi.com New York The data controller responsible for your personal information for the purposes of GDPR compliance is: SUSAN RAZAVI susan@susanrazavi.com
New York The data controller responsible for your personal information for the purposes of GDPR compliance is: SUSAN RAZAVI susan@susanrazavi.com Disclosure: COPPA compliance Disclosure: This Privacy Policy presumes that your website is not directed at children under the age of 13 and does not knowingly collect personal identifiable information from them or allow others to do the same through vour site. If this is not true for your website or online service and you do collect such information (or allow others to do so), please de aware that you must be compliant with all COPPA regulations and guidelines in order to avoid violations which could lead to law enforcement actions, including civil penalties. In order to be fully compliant with COPPA your website or online service must fulfill other requirements such as: posting a privacy policy which describes to delete it, and retuse to allow any further collection or use of the child’s information, and the procedures to exercise their rights); (v) give parents “direct notice of your intormation practices delore collecting information from their children; and (v) obtain the parents vertable consent belore collecting, using or disclosing personal information from a child. For more information on the definition of these terms and how to make sure your website or online service is fully compliant with COPPA please visit https://www.ftc.gov/tips-advice/business-center/guidance/childrens-online-privacy-protection-rule-six- compliance.
Susan Razavi LCSWR
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