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Informed Consent Form

Informed Consent Form

  • Welcome: This informed consent is designed to answer your general questions about the services provided by Azizeh E. Rezaiyan, MA, MFT an independent private practitioner. By signing this informed consent form, you consent to participate in counseling/psychotherapy with Azizeh E. Rezaiyan, MA, MFT.

  • What is Psychotherapy? Marriage and Family Therapists help individuals, couples and families of all ages and diversity to solve emotional problems with the goal of improving interpersonal relationships. Therapy is an interactive process that requires active involvement on your part. Good communication between therapist and client(s) is probably the most important factor in having a successful outcome. As a client, you have the right to ask the therapist questions about their qualifications, background, and theoretical orientation. In some instances talking about problems and painful experiences may make symptoms worse in short term, however over time you should see an improvement. In addition, not all people benefit from therapy or working with a therapist. If at any time during the therapy you have questions about whether or not the treatment is effective, feelings about something I did or said, or need explanations on the goals, please do not hesitate to bring this up in the session.

    Telephone: You may reach me by calling (650) 206-9973. I check my messages several times a day and am generally able to return calls within no more than 24 hours. In the event that I am away on vacation, my voice mail will leave the name and number of another therapist who is covering for me.

    Fees:Like many professionals within my field, I am not part of an insurance network. I try to keep my fees as low as possible. My fees are a reflection of my dedication to you, and below the local average. To learn more about the information you need to have and questions to ask from your insurance company, for out-of-network (PPO) mental health coverage, please visit my website by clicking on “Fees”.

  • Please enter the fee which was agreed upon in advance between Azizeh and the client.

  • Cancellation: For therapy to be effective, it is important to attend your appointments as scheduled. If you are unable to keep an appointment, please notify me. If I do not receive 48 hours notice of your need to cancel an appointment, I will need to charge the time reserved for you. If you are using your insurance benefits to pay for therapy, your insurance company will not pay for missed session or for late cancellations. Therefore, you will be responsible for the full regular hourly fee.

    Confidentiality: The information between therapist and client is held strictly confidential, unless:

    1. If there is an evidence of child or elderly abuse.
    2. If the therapist learns that there exists a serious threat to the client life or the life of another.
    3. If you sign a release of information as part of your insurance form or you are referred by an EAP or Managed Care Company that request information.
    4. If you sign a release of information for the therapist to share information with specific others.
    5. If there is a court order for the therapist to appear or produce records.

    I hereby make application for myself, or my minor child whose name is entered below, to receive care and treatment from Azizeh E. Rezaiyan, MFT.I hereby certify that I understand and agree to the above policies. I have received a copy of the above pages and I have received a copy of “Notice of Privacy Practices.