Print this form, sign it, and bring it to your first appointment.
Psychotherapy is a collaborative process. Progress depends on honest communication, consistent attendance, and a willingness to engage with the work between sessions. Dr. DioGuardi will work with you to establish treatment goals and will periodically review your progress. You have the right to ask questions about your treatment at any time and to discontinue services at any time.
The therapeutic relationship is professional in nature. Dr. DioGuardi does not engage in dual relationships (e.g., social, business, or personal relationships outside of therapy) with current or former clients, as these can compromise the integrity of the therapeutic process.
Sessions are typically 45–50 minutes in length and are scheduled at a mutually agreed-upon time. Please arrive on time; late arrivals will not extend the session beyond the scheduled end time. If you are running late, please call or text to let the office know.
In the event that Dr. DioGuardi must cancel an appointment, you will be notified as early as possible and the session will be rescheduled at no charge to you.
Session fees will be discussed and agreed upon prior to the start of treatment. Payment is due at the time of service unless other arrangements have been made in advance.
Dr. DioGuardi is an out-of-network provider. He does not bill insurance companies directly. Upon request, a detailed superbill (itemized receipt) will be provided after each session, which you may submit to your insurance carrier for potential out-of-network reimbursement. It is your responsibility to understand your insurance benefits.
Credit Card on File (Optional): You may choose to leave a credit card number on file for the convenience of automatic billing at the time of each session, or to cover any outstanding balances including late-cancellation fees. Your card information is stored securely and will never be charged without your prior knowledge, except in the case of an agreed-upon outstanding balance. Please indicate your preference in the signature section below.
Accounts with outstanding balances of 60 days or more may result in a pause in services until the balance is resolved.
Phone & Voicemail: The office phone number is (914) 233-7177. Dr. DioGuardi checks voicemail regularly. You can expect a return call or text within 24 hours on business days (Monday–Friday). Messages left over the weekend or on holidays will be returned on the next business day.
Text Messaging: Text messaging is available for brief, administrative communications only — such as appointment reminders, scheduling changes, or a quick check-in. Text messaging is not appropriate for clinical matters, crisis situations, or anything requiring a detailed response. Please do not use text to communicate sensitive clinical information, as standard SMS is not encrypted and cannot be guaranteed to be confidential.
Email: Email may be used for scheduling and administrative purposes. As with text messaging, please do not send sensitive clinical content via email. Dr. DioGuardi will respond to emails within 24 hours on business days.
Between-Session Contact: Dr. DioGuardi is not available for ongoing between-session support or crisis counseling by phone or text. If you are experiencing significant distress between sessions, please contact a crisis line or proceed to your nearest emergency room.
Additional crisis resources:
Dr. DioGuardi's office is not a crisis service and cannot guarantee immediate availability outside of scheduled sessions. If you are unsure whether your situation constitutes an emergency, please err on the side of caution and call 911 or 988.
All information shared in therapy is strictly confidential. Dr. DioGuardi will not disclose information about you to any third party without your written authorization, except as required by law. Please refer to the separate HIPAA Notice of Privacy Practices for a full description of your privacy rights and the limited circumstances under which disclosure may be required without your consent (e.g., imminent danger, mandatory reporting, court order).
Telehealth sessions are conducted via a HIPAA-compliant, encrypted video platform. You are responsible for ensuring a private, distraction-free environment during telehealth sessions. Telehealth is not appropriate for all clinical situations; Dr. DioGuardi reserves the right to recommend in-person sessions when clinically indicated. You must be physically located in New York State during all telehealth sessions.
To protect your confidentiality and maintain appropriate professional boundaries, Dr. DioGuardi does not accept friend or connection requests from current or former clients on any social media platform. If you encounter Dr. DioGuardi on social media, please do not initiate contact through those channels.
Dr. DioGuardi maintains clinical records in accordance with New York State law and professional ethical standards. Records are retained for a minimum of seven years following the termination of services (or until a minor client reaches age 21, whichever is later). You have the right to request a copy of your records; a reasonable administrative fee may apply. In some circumstances, Dr. DioGuardi may determine that sharing certain records could be harmful and may provide a treatment summary instead.
Either party may terminate the therapeutic relationship at any time. If you wish to discontinue services, please discuss this with Dr. DioGuardi so that an appropriate termination plan can be developed. Dr. DioGuardi may also initiate termination if continued treatment is not clinically indicated, if there is a conflict of interest, or if fees remain unpaid. In all cases, referrals to other providers will be offered as appropriate.
Acknowledgment & Agreement
By signing below, I confirm that I have read, understood, and agree to the Office Policies and Informed Consent described in this document. I understand that these policies are in place to support a safe, effective, and professional therapeutic relationship. I have had the opportunity to ask questions, and any questions I had have been answered to my satisfaction.
Credit Card on File (Optional)
I authorize Dr. DioGuardi's office to securely store my credit card information for billing purposes. I understand my card will only be charged for agreed-upon session fees or outstanding balances, and I will be notified in advance.
If yes, your card number will be collected securely at your first appointment — please do not write card numbers on this form.
Please print, sign, and bring this completed form to your first appointment.
A copy will be retained in your clinical record. Questions? Call (914) 233-7177 or email rjd@drdioguardi.com.