TN Marriage and Family Therapy PLLC
1329 East 13th Street, Brooklyn, NY
Phone: 818-298-2759
Email: rtzvinoble@gmail.com

1. Introduction

Welcome to TN Marriage and Family Therapy PLLC. This document outlines important information about therapy services, your rights as a client, and our practice policies. Please read carefully and ask any questions before signing.

2. Nature of Therapy

Therapy is a collaborative process that may involve discussing difficult emotions, experiences, and relationships. While many clients benefit from therapy, outcomes cannot be guaranteed.

You have the right to:

• Ask questions at any time
• Decline to answer questions
• Request changes in treatment approach
• Withdraw from therapy at any time

3. Confidentiality

Your information is kept confidential in accordance with New York State law and professional ethics.

Exceptions to confidentiality include:

• Risk of serious harm to yourself or others
• Suspected abuse or maltreatment of a child (mandated reporting)
• Court order, subpoena, or legal requirement
• Written authorization from you
• Professional consultation or supervision (limited to necessary information)

4. Mandated Reporting

All clinicians at TN Marriage and Family Therapy PLLC are mandated reporters under New York law and are required to report suspected child abuse or maltreatment.

5. Supervision

Some clinicians may be practicing under supervision. In such cases, aspects of your care may be reviewed by a qualified supervisor to ensure quality of treatment. Identifying information is shared only as necessary.

6. Telehealth (if applicable)

Telehealth services may be used when appropriate. While convenient, telehealth carries risks including potential interruptions, technical difficulties, and limits to privacy. By participating, you consent to these risks. 

7. Appointments & Cancellation Policy

Sessions are typically scheduled in advance.

• Cancellation policy:At least 24 hours’ notice is required
• Late cancellations or missed appointments may be subject to a fee

8. Fees & Payment

• Fees will be discussed prior to starting treatment
• Payment is due at the time of service unless otherwise arranged
• Clients are responsible for any fees not covered by insurance

9. Communication

• Phone and email may be used for scheduling and administrative purposes
• These methods are not fully secure; avoid sharing sensitive clinical information
• Responses may not be immediate

10. Emergencies

TN Marriage and Family Therapy PLLC does not provide 24/7 crisis services.

In case of emergency:

• Call 911
• Go to the nearest emergency room
• Contact 988 (Suicide & Crisis Lifeline)

11. Client Rights

You have the right to receive ethical, respectful, and professional care.
If you have concerns, you may discuss them directly with your therapist.

12. Consent to Treatment

By signing below, you acknowledge that:

• You have read and understand this document
• You have had the opportunity to ask questions
• You consent to receive therapy services from TN Marriage and Family Therapy PLLC
• You understand the limits of confidentiality
• You agree to the practice policies outlined above

Client Name: __________________________

Signature: _____________________________ Date: __________

Therapist Name: ________________________

Signature: _____________________________ Date: __________