Informed Consent Policy
Last updated: February 1st, 2026
DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY. In an emergent situation do not proceed with using this service, but instead: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).
We are pleased you have chosen Agave Medical NY, P.C. (“Agave Medical”) (or any other Medical P.C. of Agave) for your tele-behavioral health needs. This consent form is intended to inform you of how the therapeutic relationship works, what you can expect of your mental health clinician in terms of his/her/their credentials, and in connection with the psychotherapy you will receive at Agave Medical via telehealth. After you have carefully read this document, and had an opportunity to have your questions answered, it is required that you sign and date this informed consent before commencing services.
YOUR THERAPIST’S CREDENTIALS. Your mental health clinician’s credentials were made available to you before scheduling an appointment, and your therapist is licensed in the state in which you reside, New York. Our mental health clinicians include skilled and experienced Licensed Mental Health Counselors, Licensed Clinical Social Workers, and equivalent licensed professionals. They each use a collaborative treatment process wherein they work with you on identified goals for overall improvement and changes you deem important or necessary to improve the quality of your life. If you have any questions about your therapist’s credentials, please direct them to your mental health clinician.
In some cases, your therapist may be providing psychotherapy under supervision due to not yet having received independent licensure. If this is case, your therapist will provide you with the name and contact number of his/her/their supervisor whom you might contact regarding any issues that might arise between you and the therapist.
While you can expect benefits from this treatment, no particular outcome can be guaranteed, and you are free to discontinue treatment at any time, but in that case it would be best to discuss with your therapist any plans to end therapy before doing so. Your discussion with your therapist about therapy will include the therapist's evaluation and diagnostic formulation of your challenges, the method of treatment, goals and length of treatment, and information about record-keeping. You will be informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. Therapy can sometimes cause upsetting feelings to emerge; you may feel worse temporarily before feeling better, and this may include experiencing some distress caused by changes you may decide to make in your life as a result of therapy.
MEDICAL CONSULTATION UNDER LIMITED CIRCUMTANCES. Depending on the licensure of your therapist, you may be required to attend a consultation with a licensed physician if you present with symptoms tantamount to one of the following conditions: Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Panic Disorder, Obsessive-Compulsive Disorder, Attention-Deficit Hyperactivity Disorder and/or Autism in order to proceed with therapy.
IN THE EVENT OF A CRISIS OR EMERGENCY. Please note that your therapist does not provide 24-hour or emergency crisis services, and cannot provide emergency service. If you are experiencing a psychiatric or medical emergency, please call 911 immediately or go to the nearest emergency room.
If you are in crisis but not in immediate danger, you may also contact:
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The 988 Suicide & Crisis Lifeline by dialing 988 (available 24/7), or
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The NYC Well hotline at 1-888-NYC-WELL (1-888-692-9355).
CONFIDENTIALITY. Information about psychotherapy is almost always kept confidential by the therapist and not revealed to others unless a client provides consent. There are a few exceptions as follows:
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Therapists in New York State are required by law to report suspected child abuse or neglect to the proper authorities.
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Therapists are also mandated to report to the authorities clients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such clients are owners of firearms, and if they are, or apply to be, then limiting and possibly removing their ability to possess them.
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If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner that presents a substantial risk of incurring serious bodily harm.
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If a client threatens grave bodily harm or death to another person.
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If a client is involved in certain court proceedings the therapist may be required by law to reveal information about the treatment. These situations include child custody disputes, cases where a therapy client's psychological condition is an issue, lawsuits or formal complaints against the therapists, civil commitment hearings, and court-related treatment.
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Diagnosis and dates of service may be shared with an insurance company to collect payments.
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Information may be released as outlined Agave Medical’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.
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The therapist may consult with other therapists at Agave Medical about your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies, but in doing so will not reveal a client’s name or other identifiable information. Further, when the therapist is away or unavailable, another therapist might provide coverage and so will need to have some information about the treatment. regarding your treatment. All Agave Medical team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent.
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If a client’s account becomes overdue and the amount due is not paid and a payment plan is not agreed upon, a limited amount of information about the treatment may be revealed in taking legal measures to be paid.
In all of the situations described above, the therapist will try to discuss the situation directly with the client, or notify the client, before any confidential information is revealed if possible, and will reveal only the least amount of information that is necessary.
SCHEDULING AND CANCELLATIONS. Please carefully review the following Scheduling and Cancellations Policy: sessions with your therapist are booked on the Agave Health App; cancellations and rescheduling can happen without any late cancellation fee up to 48 hours prior to the originally scheduled time of the session. Late cancellations with less than 48 hours notice will be charged a late cancellation fee up to the cost of the session. In case of emergency cancellations, please reach out to your therapist through your direct chat channel on the Agave Health App, so the therapist can elect to forego the late cancellation fee. By signing this document, you are attesting that you have read, understood and will comply with this Scheduling and Cancellations Policy.
FEES AND BILLING ARRANGEMENTS. Prices are subject to change. You will be charged the fees for your telehealth services upon completion of each session; however, you are not obligated to pay any fees for which another party (e.g., your employer or health plan) pays on your behalf. If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing at hello@agavehealth.com regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).
You also hereby authorize the direct payment of all insurance and plan benefits otherwise payable to or on your behalf for services rendered to Agave Medical. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for services provided to you.
IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. Agave Medical offers individual, scheduled counseling and psychotherapy sessions by means of telehealth.
Consent to Telehealth Services
Telehealth (also referred to as telemedicine or tele-behavioral health) involves the delivery of psychotherapy services using interactive audio-video communication technology and may include evaluation, diagnosis, consultation, and treatment. With client consent, telehealth services may also involve the electronic communication of health or mental health information to other health care providers when clinically appropriate.
Voluntary Participation and Right to Withdraw
Participation in telehealth services is voluntary. Consent to telehealth may be withheld or withdrawn at any time, without penalty, by notifying the provider.
Confidentiality and Its Limits
The laws protecting the confidentiality of health and mental health information apply to telehealth services. Information disclosed during psychotherapy is generally confidential; however, there are legal and ethical exceptions, including mandatory reporting of suspected child abuse or neglect, situations involving a serious or imminent risk of harm to the patient or others, and circumstances in which the patient places their mental condition at issue in certain legal proceedings.
Risks of Telehealth
Telehealth involves certain risks, including but not limited to technical failures, service interruptions, or unauthorized access to electronic communications, despite reasonable safeguards.
Nature and Limitations of Telehealth Services
Telehealth services are not appropriate for all clients, clinical presentations, or circumstances. The appropriateness of telehealth depends on a variety of factors, including clinical needs, level of risk, access to and reliability of technology, and the client’s ability to participate meaningfully in remote services. In-person services or alternative levels of care may be recommended when clinically indicated. No guarantees are made regarding treatment outcomes.
Access to Records
Clients have the right to access their medical and mental health records, including records created through telehealth services, in accordance with New York State law.
Licensure and Jurisdiction (New York State)
If the client is temporarily located outside of New York State during telehealth sessions, the client represents that they are a permanent resident of New York State. The provider is licensed in New York State, and New York State law governs the provision of services and any related professional or legal complaints.
Telehealth Informed Consent and Acknowledgment
☐ The patient has read and understands the Telehealth Informed Consent above and voluntarily consents to receive psychotherapy services via telehealth. Consent is provided electronically, and the date and time of acknowledgment are recorded by the system.
ACKNOWLEDGEMENTS
By checking the box associated with this “INFORMED CONSENT FOR PSYCHOTHERAPY TELEHEALTH SERVICES” you acknowledge that you understand and agree with the following:
You hereby consent to receiving Agave Medical’s services via telehealth technologies. You understand that Agave Medical and its providers offer telehealth-based mental health services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to the Agave Medical provider oto determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
You have been given an opportunity to select a provider from Agave Medical prior to the consult, including a review of the provider’s credentials.
You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Agave Medical will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
You understand there is a risk of technical failures during the telehealth encounter beyond the control of Agave Medical. You agree to hold harmless Agave Medical for delays in evaluation or for information lost due to such technical failures.
You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 911 immediately and that the Agave Medical providers are not able to connect you directly to any local emergency services.
You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes.
You understand that if you participate in a consultation, that you have the right to request a copy of your medical records.
You have read this document carefully, and understand the risks and benefits of the psychotherapy and telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.
By checking the Box for this “INFORMED CONSENT FOR PSYCHOTHERAPY TELEHEALTH SERVICES” inside the Agave Health App (included under Therapy Agreements), you thereby state that you have read, understood, and agree to the terms of this policy.
Fees and Payment Policies
Last updated: February 1st, 2026
1. Standard Fee Disclosure and Agreement
Agave Medical charges a standard fee of $175 for approximately 45-minute individual sessions, which you are agreeing to to by signing this Agreement.
2. Cancellation Policy
Sessions with your therapist are booked on the Agave Health App. As your session time is reserved exclusively for you, at least 48 business hours’ notice is required to cancel or reschedule a session. Sessions cancelled with less than 48 business hours’ notice, or any “no show,” are charged a late cancellation fee up to the cost of the session. In case of emergency cancellations, please reach out to your therapist through your direct chat channel on the Agave Health App, so the therapist can elect to forego the late cancellation fee.
3. Payment Policies and Procedures
Payment is due at the time of each session. By using the Agave Health App services, you are authorizing Agave Health to charge the credit card you have on file at the time of service. If session length differs from the standard duration, the fee will be adjusted accordingly.
Under New York law, medical bills paid by credit card are no longer considered medical debt. By paying with a credit card, you are foregoing federal and state protections around medical debt, including prohibitions against wage garnishment and property liens, prohibitions against reporting medical debt to credit bureaus, and limitations on interest rates. Please initial here indicating your acknowledgement that each time that you pay for our services with a credit card you are foregoing the above-mentioned protections: _____
4. Payment Option Selection (Select One)
A. Self-Pay (No Insurance Billing)
I agree to pay the full fee directly to Agave Medical at the time of service. Good Faith Estimate: per the No Surprises Act, you can request a Good Faith Estimate of expected charges, or decline a Good Faith Estimate at time of booking. I understand that insurance will not be billed, and that I am solely responsible for all charges.
B. In-Network Insurance
Agave Medical will bill my insurance as an in-network provider. I understand that I am responsible for all co-payments, co-insurance, deductibles, non-covered services, and any balance not paid by my insurance. I authorize Agave Medical to submit protected health information (PHI) reasonably necessary for billing, payment, and health care operations. Client understands that any insurance reimbursement paid directly to Client for services rendered by Agave Medical remains owed to the Agave Medical, and Client agrees to promptly endorse and remit such payment to the Agave Medical upon receipt.
C. Out-of-Network Insurance
If Agave Medical is not in-network with my insurance plan. I understand that I am fully responsible for payment of services, regardless of insurance reimbursement. As such, I authorize Agave Medical to submit out-of-network claims to my insurance as a courtesy on my behalf. I may also decline courtesy billing, and will submit claims myself. I understand that courtesy billing is not guaranteed, and that any reimbursement is determined solely by my insurance plan. If I elect courtesy billing, I authorize Agave Medical to submit PHI necessary for reimbursement.
D. Employer-Sponsored Plan / Program
Services are paid through an employer-sponsored plan or benefit arrangement. I understand that services are subject to the employer plan’s terms and limitations. Services not covered by the employer plan are my responsibility.
5. Client Financial Responsibility
Except where services are fully paid by an employer-sponsored plan, I understand that I remain financially responsible for all fees not paid by insurance or other third parties, including denied claims, non-covered services, and late payments.
6. Insurance Verification Disclaimer
Insurance verification, if performed, is a courtesy and does not guarantee coverage or payment. Final benefit determinations are made by the insurer.
7. Good Faith Estimate Statement & Disclaimer
If you are uninsured or choose to self-pay, you have the right to receive a Good Faith Estimate of expected charges. Estimates may change as treatment progresses and are not a guarantee of services, frequency, duration, or total cost. If actual charges exceed the estimate by $400 or more, you may initiate dispute resolution by contacting the U.S. Department of Health and Human Services at 1-800-985-3059 or visiting www.cms.gov/nosurprises. Initiating dispute resolution will not affect your quality of care.
8. Notice of Changes
Agave Medical reserves the right to modify payment policies with advance notice. Any changes to your fee will be discussed with you in advance.
9. Acknowledgment and Signature
By checking the box consenting to Therapy Agreements inside the Agave Health app, I acknowledge that I have read, understand, and agree to this Fee and Payment Policies Agreement and the payment option selected above.
AI Consent
1. Agave Health Inc. (“Agave Health”) and Agave Medical NY, P.C. (“Agave Medical”) use generative AI chatbots to provide administrative support to our staff. Clients can utilize a chatbot feature on their website to make an appointment, obtain client referrals, or send a secure message to their provider. The chatbot feature ("Rose") can also direct clients to the correct department for assistance.
2. Agave Medical utilizes generative AI transcription technology to generate medical notes and update a client's medical chart in real-time. Natural language processing allows the transcription software to analyze and dictate human conversations as they occur, similar to a provider’s scribe. If a client opts-in to this feature, the technology can be used during or after the client's visit when a therapist prepares after-visit summaries and updates a client's chart.
Data collected can help staff recommend ICD-11 codes for medical billing purposes and can be integrated into a client's electronic health record. The attending provider must review the transcription for quality assurance purposes before the notes are added to the client's medical chart. The vendor is HIPAA-compliant and uses two-factor authentication to prevent unauthorized access.
3. Agave Medical may retain indefinitely the unconverted source data from which session notes and treatment plans are generated by its generative AI technology. In no event however, will the unconverted source data become part of the client’s medical chart, either temporarily or permanently. The client understands that the unconverted source data are for the private use of Agave Medical as described above, that they are considered personal notes and observations under New York State law (Public Health Law Section 18), or “psychotherapy notes” as defined by federal HIPAA regulations, and that the client will not have any access to the unconverted source data at any time.
Generative AI is an aid to the provider, but ultimately the provider will make a clinical decision using their own professional judgment.
By checking the box consenting to Therapy Agreements inside the Agave Health app, you acknowledge that you have read, understand, and agree to this AI consent form. However, you can opt-out at any moment by simply informing your Agave Therapist who will then no longer leverage AI tools to support them in giving you care. The Therapist will continue providing full care regardless of your consent to AI usage.