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Practice & Provider Information

INFORMED CONSENT & SERVICE AGREEMENT

Haven Mind & Wellness LLC · Elena Rostova, MA, LMFT

Welcome to Haven Mind & Wellness LLC. This document contains important information about professional services, business policies, and confidentiality standards.

1. Services & Delivery Modality

Services are provided by Elena Rostova, MA, LMFT for individual sessions lasting 50 minutes. Secure HIPAA-compliant Telehealth video sessions only.

2. Confidentiality & Legal Exceptions

All communications are strictly confidential. By law, exceptions to confidentiality include: (a) suspicion of child, elder, or dependent adult abuse/neglect, (b) imminent danger of physical harm to oneself or others, and (c) valid court subpoena or mandatory judicial orders.

3. Professional Fees & Cancellation Policy

The fee per session is $160, payable at the time of each appointment. If you must cancel or reschedule an appointment, you agree to provide at least 24 hours advance notice. Cancellations made with less than the required notice will be billed at the full session rate.

4. Emergency & Crisis Services

This practice does not provide 24/7 on-demand crisis intervention. If you are experiencing an acute mental health crisis or physical emergency, please call 988 (Suicide & Crisis Lifeline), call 911, or report to the nearest hospital emergency room.

Client Printed Name & Signature
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