1.Read the Informed Consent 2.Sign the Acknowledgement of Receipt of Informed Consent Sign here Acknowledgment Name * By signing the Disclosure Statement and Agreement for Services Summary, you have agreed to abide by "Informed Consent" agreement. Please feel free to discuss the contents of this agreement with me. I understand that I am financially responsible to therapist for all charges, including unpaid charges by my insurance company or any other third-party payer. First Name Last Name Date MM DD YYYY Thank you! 3.Application of Services Application Form Application of Services Name: * First Name Last Name Email: * Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone: * May I leave a message at this number? * Yes No Occupation: * Employer: * Date of birth: * Gender: * Marital status: * Years married: Persons to notify in case of emergency (name, phone number, relationship): * Current medications: * Do you have any allergies? * Who lives in your home with you? (name, age, relationship) * Have you ever been hospitalized for medical and/or psychiatric reasons? If yes, please list the reasons, the dates and the outcome of your hospitalization. * Please list any active and previous addiction history. * Please provide any examples of daily self-care that you follow. * Thank you! 4.Read the Telemedicine Consent 5.Sign the Acknowledgement of Receipt of Telemedicine Consent Sign here Ackowledgement Name * I have read and understand the information provided. I consent to the conditions of telemedicine, and all of my questions have been answered to my satisfaction. First Name Last Name Date * MM DD YYYY Thank you! 6.Read the Good Faith Estimate 7.Authorization to Release Confidential Information Authorization I hereby authorize Pouneh Azadi to release confidential information obtained during the course of my work. This Authorization permits the release of any and all information necessary. Release confidential information to: * For the following purpose: * The Authorization shall remain valid until: * MM DD YYYY Name: * First Name Last Name Date: * MM DD YYYY Thank you!