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.

    No Secrets Policy When a couple enters into counseling, it is considered to be one unit. This means that my allegiance is to the couple “unit,” and not to either partner as individuals. I find this is particularly important in creating a space where both partners can feel safe. Therefore, I adhere to a strict “No Secrets” policy. This means that I will not hold secrets for either partner. This policy is intended to allow me to continue to treat the couple by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.

    On occasion during the counseling process, individual partners may be seen for an individual counseling session. In this case, the individual session is still considered as part of the couple’s counseling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple. If an individual chooses to share such information with me, I will offer the individual every opportunity to disclose the relevant information and will provide guidance in this process. If the individual refuses to disclose this information within the couple’s session, I may determine that it is necessary to discontinue the counseling relationship with the couple. If there is information that an individual desires to address within a context of individual confidentiality, I will be happy to provide referrals to therapists who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples/marital counseling relationship.

    Court Proceedings/Subpoena of Records It is understood that the purpose of marital/couples therapy is for the amelioration of distress within a relationship. Therefore, if both partners request my services as a psychotherapist, they are expected not to use information given to me during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case and child custody.

    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”.

    Note: The payment is due at the beginning of our zoom session. If you choose to pay using any Apps, they may compromise their confidentiality and privacy.

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

  • Electronic communication It is very important to be aware that, email, text and cell phone communication can be easily accessed by unauthorized people, and hence, the privacy and confidentiality of such communication can be easily compromised. Emails in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all emails that go through them. For that reason, email will only be used for administrative purposes.

    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's life, family member, the life of another and collateral person.
    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.

  • Consent
    I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost.
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