Sina Safahieh, M.D.
Child, Adolescent, and Adult Psychiatrist
In order to prevent any misunderstanding concerning your psychiatric care, including contact in between
sessions, cancellation policy, responsibility for payment for services provided, please read the following
EVALUATION AND TREATMENT
First we need to clarify what the problems are and what treatment would be best for you. After the initial
assessment, we will discuss the risks and benefits of treatment options, which may include therapy or
medication treatment, or a combination of both. If you feel it is not possible for us to work together for any
reason, I will do my best to refer you to other mental health clinicians better suited for your needs.
Initial Evaluation – 60 to 90 minutes: $500.00
Follow-up Sessions (With or without medication): 50 minutes: $400.00 25-30 minutes: $200.00
Payment for services provided is due at the end of each session (cash, check, credit/debit cards). If your
account has payment overdue for over 60 days, legal means will be considered to secure payment,
including collection agencies or small claims court. There will be a $25.00 service charge for all retuned
CANCELLATIONS AND NO-SHOW POLICY
Once your appointment is scheduled, you will be expected to pay for it unless you provide at least 24
business hours advance notice of cancellation. If you do not provide at least 24 business hours notice,
or fail to show for a scheduled appointment, you will be responsible for the full cost of the session.
Insurance companies will often not reimburse for missed sessions or sessions cancelled late.
I am considered an “out of network provider” for PPO plans. Please be aware that your health insurance
policy is an agreement between you and your insurance company. All charges are your responsibility,
whether or not you have insurance. I will provide you with a statement that can be submitted to your
insurance company. Please find out from your insurance company exactly what mental health benefits
All calls to my office number are answered by voice mail. I do check for messages frequently throughout
the day, even on weekends, and return phone calls by the next business day. You are welcome to email
or text me, but I do not check for messages as regularly as I do with voicemail messages, and therefore,
I cannot guarantee that I will respond to email or text messages in a timely manner. Please be aware
that email is not a secure medium. Please contact me with questions or concerns about medication supply.
If you missed or could not make an appointment, you will be given enough medication to last until our next
rescheduled session, usually within 2 weeks.
Please call 911 or go directly to ER with any life-threatening medical or psychiatric emergency
Both the law and the standards of my profession require that I keep appropriate treatment records. You
are entitled to review a copy of the records, unless I believe seeing them would be emotionally
damaging, in which case, I will be happy to provide them to an appropriate mental health professional of
your choice. Because these are professional records, they can be misinterpreted or upsetting, so I
recommend that we review them together so that we can discuss what they contain. I can also prepare
an appropriate summary for review.
Confidentiality is of utmost importance in mental health treatment and is protected by the law. I can only
release information about our work to others with your written permission. For child and adolescent
patients, their trust in me is paramount. Before discussing a sensitive issue with the parent I will first get
the minor’s permission. I generally try to help the child/adolescent to discuss any sensitive matters with
their parents themselves.
There are exceptions to confidentiality where disclosure is required by law. These are:
-Threat of harm to self
-Threat of harm to others
-Inability to care for your basic needs (food, clothing, shelter)
-Indication of possible abuse to a child, elderly person, to disabled person
In the event of any of the above, I may have to contact other parties (ie. family members, state agency,
police, or hospital) in order to protect you or someone else.
I share an office suite with other mental health professionals. With regard to your clinical care, I am
completely independent and solely responsible. My clinical records are separately and securely