Client information

Privacy & consent forms

Read my privacy notice, review practice agreements, and find the current consent forms for AtReef Therapy, PLLC.

Dr. Ehsan Adib Shabahang provides telehealth therapy through a practice based in Cambridge, Massachusetts.

Read the privacy notice View consent forms

Current forms: Version 3.5, effective .
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Health information

Notice of Privacy Practices

How I handle your health information, your privacy rights, and how to raise a concern.

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

This notice explains how your health information is used and disclosed and describes your privacy rights.

Privacy Officer: Ehsan Adib Shabahang, PhD
Phone: (617) 906-6767
Confidential email: ehsan@therapysecure.com
Mailing address: 68 Harrison Ave, Ste 605 PMB 866561, Boston, MA 02111-1929
Website: atreef.com

Effective date of this notice

This notice takes effect on October 20, 2026.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. My pledge regarding health information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.
  • Give you this notice of my legal duties and privacy practices with respect to health information.
  • Follow the terms of the notice that is currently in effect.
  • I am also required by law to provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2.
  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

If you receive services through another company's platform, such as Alma, Grow Therapy, or Headway, that company may provide a separate or joint privacy notice. Each notice governs the entities and activities it describes. This notice does not replace a joint notice that lawfully applies to particular services or remove any entity's legal responsibilities.

II. How i may use and disclose health information about you

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For treatment, payment, or health care operations

Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures permitted by HIPAA for treatment, payment, and health care operations are materially limited by the stricter standards of those regulations. Furthermore, information disclosed pursuant to these rules may be subject to redisclosure by the recipient and may no longer be protected by federal privacy standards.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and disputes

If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. However, for records protected by 42 C.F.R. Part 2, such records or testimony relaying their content shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.

Companies supporting records, telehealth, communications, billing, or other practice functions may handle information within their authorized roles. I obtain Business Associate Agreements when required.

Redisclosure

Information lawfully disclosed outside the practice may be shared again by the recipient and may no longer be protected by HIPAA. Other confidentiality laws, including applicable Part 2 protections, may continue to apply.

III. Certain uses and disclosures require your authorization

1. Psychotherapy notes

I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

  • For my use in treating you.
  • For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
  • For my use in defending myself in legal proceedings instituted by you.
  • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
  • Required by law and the use or disclosure is limited to the requirements of such law.
  • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
  • Required by a coroner who is performing duties authorized by law.
  • Required to help avert a serious threat to the health and safety of others.

2. Substance use disorder (SUD) counseling notes

I may also maintain “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that I have already acted upon it to disclose these notes in accordance with your initial authorization.

3. Marketing purposes

As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

4. Sale of PHI

As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. Certain uses and disclosures do not require your authorization

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When required by law, limited to what the law requires, including required public health or other statutory reports.
  2. For public health and safety, including legally authorized disease prevention activities and reports of suspected child abuse or neglect, abuse of an older adult or an adult with a disability, or domestic violence when permitted or required.
  3. To prevent or lessen a serious and imminent threat, including contacting emergency responders or warning an endangered person when legally permitted or required.
  4. For health oversight, including authorized audits, investigations, inspections, and licensing proceedings.
  5. For judicial or administrative proceedings, subject to the requirements described in Section II.
  6. For law enforcement, when required by law or permitted by a specific legal exception, subject to mental health confidentiality protections.
  7. To coroners, medical examiners, or funeral directors, when performing legally authorized duties.
  8. For organ and tissue donation, when applicable law permits.
  9. For specialized government functions, including legally authorized military, national security, protective services, or correctional purposes.
  10. For workers' compensation, within applicable legal limits.
  11. For appointment reminders and care information, including contacting you about appointments, treatment alternatives, or related services. You may request a different contact method.
  12. For federal compliance reviews, including disclosures required by the U.S. Department of Health and Human Services.

I do not use or disclose your information for research or fundraising.

V. Certain uses and disclosures give you an opportunity to object

Family, friends, and others involved in your care

You may tell me whether to share relevant information with someone involved in your care or payment. I obtain written permission whenever required by applicable law. Being your partner, spouse, emergency contact, or payer does not by itself provide general access to your records.

If you cannot express your preferences, I may share relevant information based on professional judgment only when applicable law permits. A belief that disclosure is in your best interest does not override stricter confidentiality law. Disaster notifications are subject to the same legal limits.

Couples and family records

Shared records may contain information about more than one person. My policy is to obtain written permission from each adult whose confidential information would be disclosed before releasing a shared record to a third party, unless applicable law permits or requires otherwise. Each person's access request is evaluated under applicable law; another participant's refusal does not automatically eliminate a legal right of access.

VI. Your rights regarding your health information

Contact my Privacy Officer using the information above to exercise these rights. I may require a written request and verification of your identity or a representative's authority.

1. Request limits on uses and disclosures

You may ask me to restrict uses or disclosures for treatment, payment, or health care operations. I generally do not have to agree, except for the paid-in-full restriction below.

2. Restrict disclosures to your health plan for services paid in full

If you or someone other than your health plan pays for a service in full, you may request that information solely about that service not be disclosed to your health plan for payment or operations. I honor the restriction unless disclosure is required by law. Contact me before insurance billing so the restriction can be implemented.

3. Request confidential communications

You may ask me to contact you in a particular way or at a different location. I accommodate reasonable requests.

4. See and get copies of your information

You may request paper or electronic access to your health and billing records. I act within applicable deadlines, generally within 30 days under HIPAA, or sooner when state law requires. For Texas mental health records, I act as promptly as circumstances require and no later than 15 calendar days after receiving your written request. Any legally permitted extension is explained in writing. Copies are free, and an unpaid treatment balance does not prevent access. Separate psychotherapy notes and SUD counseling notes are generally excluded from federal access rights, subject to additional state rights. If access is denied, I provide the required explanation, any required summary, and information about review rights. I do not substitute a summary for records you are legally entitled to receive unless you agree. Separate storage, file ownership, or absence from the portal does not itself determine access rights.

5. Get an accounting of disclosures

You may request a list of disclosures covered by law during the preceding six years. It generally excludes treatment, payment, and operations disclosures, disclosures made with your authorization, and certain other disclosures. I generally respond within 60 days, subject to a legally permitted extension explained in writing. One accounting in any 12 months is free. I explain any lawful fee for additional accountings before you decide whether to proceed. Any additional Part 2 accounting rights apply when their compliance requirements take effect.

6. Request a correction or amendment

You may ask me to amend information you believe is incorrect or incomplete. I generally act within 60 days, subject to a legally permitted extension explained in writing. If I deny your request, I explain why and describe your right to submit a statement of disagreement.

7. Get a copy of this notice

You may request a paper or electronic copy at any time, even if you previously accepted it electronically.

8. Have a representative act for you

A legally authorized personal representative may exercise rights within the scope of their authority, subject to legal exceptions. I verify that authority first.

9. Receive breach notification

I notify you of a breach affecting your information when required by law.

10. File a complaint without retaliation

You may complain to me or the U.S. Department of Health and Human Services, Office for Civil Rights, as explained below.

Electronic communication and security

I use administrative, physical, and technical safeguards to protect your information. No system is completely secure. The client portal is the preferred way to send sensitive information. Regular email, text messages, and voicemail carry privacy risks. You may request a different communication method. Using these methods does not waive your privacy rights or my safeguarding obligations.

Privacy complaints

If you believe your privacy rights have been violated, contact me as Privacy Officer by phone, email, or mail using the information at the beginning of this notice. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, including about applicable Part 2 protections:

  • Online: HHS privacy complaints
  • Phone: (800) 368-1019; TDD: (800) 537-7697
  • Mail: U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201

You do not have to complain to me first. I will not retaliate against you for filing a complaint.

Acknowledgment of receipt of privacy notice

By signing electronically, I confirm that I reviewed this agreement, had an opportunity to ask questions, and agree to the items contained in this document.

SimplePractice records my electronic signature and date. Each participating adult signs their own copy.

Ehsan Adib Shabahang countersigns electronically, with the date recorded.

Practice forms and privacy information: atreef.com/privacy-policy

Practice documents

Open a document to read it here, or download its individual PDF.

The forms you receive depend on your services and payment arrangement. AI tools, session recording, and sharing recordings are separate optional choices, as described in those forms.

Consultation and treatment

Couples and Family Therapy Agreement

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

This agreement explains the arrangements for couples and adult family therapy.

Who the clients are and the purpose of treatment

In this service, the participating adults are clients in joint treatment focused on their relationship or family system. We identify the participants and shared goals at the outset and clarify any change in who is participating. A person invited only to provide support or information is not automatically a therapy client; I clarify that person's role before participation.

I work toward the agreed therapeutic goals rather than acting as one participant's advocate, deciding legal fault, or serving as a judge. Treatment may support improved communication, trust, connection, or informed decisions about a relationship, including separation. The main consent explains benefits, risks, alternatives, and the absence of a guaranteed outcome.

Assessment and separate meetings

Assessment usually includes a joint intake, separate meetings with each participant, questionnaires, and a feedback discussion. I explain the purpose of questionnaires and identify any outside assessment platform before use. We discuss findings and agree on a treatment plan.

A separate meeting conducted as part of joint treatment remains part of that service. It does not establish a separate individual therapy relationship or a separate promise of confidentiality inconsistent with applicable law and the policy below. I explain the privacy arrangements before separate meetings or questionnaires.

I do not simultaneously provide ongoing individual therapy to a participant while serving as the couple's or family's therapist. After joint work ends, any request for individual therapy requires a new assessment of conflicts and clinical appropriateness; a referral to another clinician is often preferable.

Information shared separately: no-secrets policy

Joint treatment requires a workable agreement about significant information. I do not agree to keep relationship-relevant information indefinitely secret when doing so would undermine appropriate joint care. This includes information provided in separate meetings, questionnaires, calls, messages, or emails.

If important information arises privately, I discuss with you how it affects treatment and, when appropriate, help you plan a safe disclosure. I do not repeat every private comment or automatically disclose private information to another participant. Any disclosure must be lawful. Where a separate written authorization is required, I obtain it; this agreement does not replace that authorization.

If unresolved secrecy or a conflict about information prevents safe and clinically appropriate joint care, I may pause, change, or end joint treatment and discuss referrals. This does not give me authority to compel an authorization or disclosure. I consider safety, confidentiality, and continuity rather than using disclosure as a threat or punishment. A legally permitted or required safety disclosure is handled under the privacy notice and applicable law.

Relevant information from separate contacts may be documented in the joint treatment record. Record-access rights are addressed below and in the Notice of Privacy Practices.

Safety and between-session contact

Tell me privately about violence, coercion, threats, monitoring, fear, or possible retaliation. I assess whether each person can participate freely, including through separate safety screening when appropriate. Joint work may be unsuitable when participation increases danger or when an acute condition requires different care.

When appropriate, I may pause joint sessions, arrange a different assessment or safety plan, or recommend another service. I do not promise to disclose safety information to another participant or promise that any action is risk-free. I follow applicable legal and professional duties.

Keep routine between-session contact focused on scheduling and practical matters. Include other participants when safe and appropriate. You may contact me privately about safety. Significant separate clinical communications are addressed under the information-sharing policy above. Messages are not an emergency service.

Attendance and fees

If one participant is temporarily unavailable, a session with those present may proceed only when I agree it is clinically appropriate and within the ongoing joint treatment plan. Such a meeting remains part of couples or family therapy; the applicable couples or family fee applies, as described in the Financial and Billing Agreement.

A participant's withdrawal is different from a temporary absence. A continuing individual therapy relationship does not arise merely because someone attends alone. We reassess the format when attendance changes undermine joint work.

The Financial and Billing Agreement governs payment responsibility, cancellations, and missed appointments. This agreement does not create a new fee, impose a new payment obligation on someone who has not agreed to it, or authorize card charges.

Joint records and privacy

Joint treatment uses a shared clinical record that may include relevant information from joint and separate meetings. I explain who is identified as the primary client for record administration or billing. That designation does not by itself determine anyone's legal access or confidentiality rights.

Billing documents may identify the person billed, service type, and any clinically appropriate diagnosis. Before issuing documents to another participant, payer, or third party, I address applicable consent and confidentiality requirements. Payment for treatment does not by itself authorize access to another person's confidential information.

Third-party release of shared confidential information follows the Notice of Privacy Practices, including the practice policy of obtaining permission from each affected adult unless an applicable legal exception permits or requires otherwise. Each person's own access request is evaluated separately under the law; another person's objection does not automatically eliminate a legal right of access. Lawful protection or redaction of another person's information may be necessary.

I ask each participant to protect information learned about others in therapy. I cannot guarantee that another participant will keep it confidential. No one may record, screenshot, livestream, or use external transcription or AI tools without prior agreement and all required permissions, subject to applicable legal rights and accommodations. This agreement does not prohibit lawful reviews, complaints, protective actions, or use of legal rights.

I am a treating clinician, not a custody, parenting, fitness, or forensic evaluator. I do not provide legal-advocacy opinions for one participant against another. Requests for records or testimony are reviewed under applicable confidentiality, privilege, and legal-process requirements. A subpoena does not automatically authorize disclosure, and this agreement does not prevent lawful process or guarantee that a court will protect the record. Any compelled response remains subject to applicable legal limits.

Legal or additional professional work is addressed through the Financial and Billing Agreement and applicable law. No new testimony rate or automatic liability is created here.

AI documentation, retained session recordings, and sharing recordings for Gottman consultation or certification review remain separate choices. Each participating adult must provide the applicable consent or authorization before the activity occurs. Any participant may decline or withdraw an optional consent as described in that form; joint therapy may continue without the optional activity.

Withdrawal, changes, and ending joint treatment

Either partner may withdraw from couples therapy. If a partner withdraws, I stop the joint treatment and discuss appropriate next steps and referrals. I do not continue treating the remaining person as though couples therapy were still occurring.

In adult family work, a participant's withdrawal requires reassessment of whether appropriate therapy can continue with the others, what the new goals and privacy arrangements would be, and whether a revised agreement is needed. Continuing care is not automatic.

I may also recommend pausing, changing, or ending joint treatment when conflicts of interest, safety, unmet consent requirements, or clinical needs prevent appropriate work. The notice, referral, and continuity provisions in the main consent apply. I explain material changes before implementing them and obtain a revised agreement when needed.

By signing electronically, I confirm that I reviewed this agreement, had an opportunity to ask questions, and agree to the items contained in this document.

SimplePractice records my electronic signature and date. Each participating adult signs their own copy.

Ehsan Adib Shabahang countersigns electronically, with the date recorded.

Practice forms and privacy information: atreef.com/privacy-policy

Download couples and family therapy form (PDF)

Fees and payment

Financial and Billing Agreement

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

This agreement explains the fees, payment arrangements, and financial policies for your services. A person separately agreeing to pay also signs the applicable financial terms.

Financial responsibility

A client receives services, a financially responsible person agrees to pay, and a cardholder separately authorizes charges to their card. These roles may belong to different people. Paying does not grant access to treatment information or records.

For couples, both partners signing this agreement are jointly responsible for agreed fees unless a different arrangement is confirmed in writing. For adult family therapy, the adults expressly identified in writing as responsible for payment pay the agreed fees. Applicable law and payer or platform requirements control. Separation, disagreement, or ending therapy does not erase an existing lawful balance.

Standard private-pay fees

These fees apply to services confirmed for direct AtReef Therapy, PLLC private-pay billing. They do not automatically apply to insurance or platform-billed sessions.

  • Consultation, up to 30 minutes: no charge.
  • Initial diagnostic assessment, up to 60 minutes: $350.
  • Individual therapy, generally 50 to 53 minutes: $300 per session.
  • Couples therapy, generally 50 to 53 minutes: $350 per session.
  • Adult family therapy, generally 50 to 53 minutes: $350 per session.
  • Late cancellation or missed session: $200 when applicable under the policy below.
  • Additional professional services: $300 per hour for individual work or $350 per hour for couples or family work, billed in 15-minute increments.
  • Voluntary factual testimony: $1,000 per hour for preparation, travel, waiting, and attendance, when accepted and permitted by applicable law or court requirements.
  • Formal assessment packages: starting at $700.
  • Brief scheduling messages or calls, record copies, brief progress summaries, and authorized record transmission: no charge.

Phone and video therapy sessions have the same rates. A separate meeting with one partner as part of couples therapy remains part of that service and is charged at the couples rate. Any different agreed rate is documented in writing and remains in effect until properly changed.

Assessment packages

Before the assessment process begins, I send an invoice identifying the assessment, included services, and total fee. Payment is due in full before I order materials, provide assessment access, or begin assessment work.

Included meetings, scoring, interpretation, and reports are not charged again at therapy or additional-work rates. Optional additional work requires your prior written approval.

If you cancel or stop before completion, unused prepaid funds are refunded after deducting completed services at agreed rates, any nonrecoverable test or material costs disclosed before payment, and any applicable appointment cancellation fee without duplicate charges. The general billing, cancellation, interrupted-session, dispute, and Good Faith Estimate provisions here also apply.

Assessment consent is addressed in the Informed Consent for Psychotherapy and Assessment Services and documented before the assessment begins. Paying an invoice does not authorize disclosure of results.

Direct and platform billing

For confirmed direct private-pay services, payment is due on the service date unless otherwise agreed in writing, except assessment packages, which must be paid in full before the assessment process begins.

Credit and debit cards, including eligible HSA/FSA cards, are accepted through SimplePractice. Cash, checks, and other payment apps are not accepted. Charges require the applicable cardholder authorization. A receipt is provided through the portal or email. AtReef Therapy, PLLC does not submit insurance claims for these direct private-pay services.

Sessions established for billing through Headway, Grow Therapy, Alma, or another billing platform remain billed there unless a permitted change is confirmed in writing. Applicable platform and payer requirements govern charges, cancellation limits, payment methods, processing, and refunds. The platform manages its systems; I remain responsible for my own services, accurate submissions, lawful disclosures, and corrections requiring my action.

Contact the platform about its account, claims, or payment processing, and contact me when my services or submissions are involved. Keep payment and insurance information current in the account used for billing. Updating a separate AtReef Therapy, PLLC account does not automatically update the platform.

A change to direct billing requires advance confirmation that it is permitted by law, payer obligations, and platform agreements. We document the new arrangement, fees, effective date, and any continuing required information sharing. Earlier sessions keep their original billing arrangement, subject to necessary corrections. A booking-only referral does not determine the payment arrangement.

A denied claim, declined card, or unpaid platform balance does not by itself authorize a separate direct charge by AtReef Therapy, PLLC. I do not collect duplicate payment for the same amount owed. Choosing not to use an available insurance benefit may require a separate lawful self-pay election. This agreement does not waive insurance benefits or bypass Medicare, Medicaid, or other payer requirements.

Insurance and itemized statements

When your plan and the applicable arrangement permit, you may request an itemized statement or superbill to seek reimbursement yourself. Reimbursement and eligibility are determined by your plan and are not guaranteed. I remain responsible for my own participation and billing obligations.

Statements may include identifying information, a clinically appropriate diagnosis, service dates, codes, and fees. Joint-therapy statements may identify the person billed and any applicable diagnosis. Disclosure to another participant or payer remains subject to applicable confidentiality and authorization requirements. A self-pay election may affect whether a reimbursement statement is appropriate.

I report actual services, dates, duration, and clinically supported diagnoses. Cancellation charges, testimony, and other non-therapy work are not billed as completed psychotherapy.

Cancellations and attendance

Cancel or reschedule as soon as possible and at least 48 clock hours before the appointment. This includes weekends and holidays. Notify me through the client portal, by calling (617) 906-6767, or by emailing ehsan@therapysecure.com. Notice counts when sent through one of these methods.

For direct private-pay appointments, less than 48 hours' notice or a missed appointment ordinarily results in a $200 fee. I may reduce or waive it for emergencies or circumstances beyond your control. One waiver does not change the policy for future appointments. There is no cancellation fee when I cancel or reschedule.

For platform-billed appointments, this policy applies only to the extent permitted by the platform, payer, and law. Any required shorter notice period, lower fee, or prohibition on a fee controls. An unkept appointment is not billed as completed therapy.

Late arrival does not extend the scheduled ending time. If treatment proceeds, the agreed session fee ordinarily applies, subject to applicable billing requirements. If too little time remains for appropriate treatment and the appointment is treated as missed, the applicable missed-session policy applies instead. I do not charge both a session fee and a cancellation or missed-session fee for the same appointment.

A session prevented by an unauthorized location, driving, impairment, or an unsafe or nonprivate setting may be treated as a late cancellation when this policy applies, subject to emergency, clinical-safety, legal, and payer exceptions. Attendance by fewer participants in couples or family work requires my agreement and clinical appropriateness, as described in the Couples and Family Therapy Agreement. Repeated attendance problems may require a review of scheduling or care.

Interrupted sessions

When technology interrupts a session, we attempt to reconnect or continue by telephone when appropriate. If a problem on my end prevents completion, we agree on an appropriate fee adjustment or replacement time.

Client-side interruptions are handled according to the services provided, the agreed attendance policy, and applicable payer requirements. A widespread outage outside both parties' control is not treated as a late cancellation. I do not submit insurance claims for treatment that was not provided.

Additional work may include detailed letters, reports, forms, requested document review, coordination with outside parties, or substantive calls and messages beyond brief scheduling. Before optional additional work, I describe the service, provide an estimate, and obtain your written approval. Any advance payment is agreed separately. I obtain further approval before exceeding the estimate, and unused prepaid funds are refundable.

These arrangements do not delay legally required record access, emergency action, or compliance with legal obligations. Required confidentiality permissions must be obtained before information is sent to another party. I may decline work outside my role or competence, unsupported requests, or work that would compromise appropriate care.

I am a treating therapist, not a forensic evaluator, expert witness, or legal advocate. Voluntary factual testimony requires a written agreement and advance estimate; any advance payment is specified there. Compelled work and related charges are handled only as applicable law or a court permits. A subpoena does not automatically authorize disclosure. Payment terms do not waive record-access, confidentiality, or complaint rights.

Refunds, disputes, and unpaid balances

For AtReef Therapy, PLLC-processed payments, I initiate refunds of confirmed overpayments, billing corrections, and unused prepaid funds to the original card within five to seven business days after confirmation, or sooner when required by law. Bank posting may take longer. At your written request, an eligible credit may be applied to future services. Platform refunds follow the platform's process, with my cooperation when required.

For direct billing questions, contact me at (617) 906-6767 or ehsan@therapysecure.com. A chargeback does not by itself determine whether a debt is valid or erase a lawful balance. Your legal dispute and complaint rights remain intact.

If payment fails, I or my authorized office assistant notify you. After notice, an unresolved balance may lead to a payment arrangement, a pause in nonurgent scheduling, an appropriate transition or termination with referrals, or lawful collection. These decisions consider safety, continuity, and professional obligations. Record copies are not withheld because treatment fees remain unpaid.

Any collection disclosure is limited to necessary identifying and billing information, subject to applicable confidentiality law and required agreements. Session notes and therapy content are not provided for routine collection.

Good faith estimates

If you are uninsured or not using insurance, you have the right to a written Good Faith Estimate of expected charges for nonemergency care, provided within applicable legal deadlines. You may request one before scheduling. An estimate is not a commitment to obtain services or a guarantee of treatment duration. It is updated when legally required. This agreement does not replace your estimate or required notices.

If a provider's total billed charges are at least $400 above that provider's estimated charges, you may qualify for federal patient-provider dispute resolution. The process generally must be initiated within 120 calendar days after receiving the initial bill. Information is available at https://www.cms.gov/nosurprises or (800) 985-3059. Signing this agreement does not waive these rights.

While an applicable federal patient-provider dispute is pending, I suspend existing collection efforts and late-fee accrual as required. I do not initiate or threaten collection of the disputed bill or retaliate for using the process.

Changes to this agreement

I provide at least 30 days' written notice before changes to fees or financial policies. Changes apply prospectively. Individual payment arrangements are documented in writing, and applicable platform and payer requirements continue to apply. Applicable law controls over any conflicting provision; any remaining enforceable provisions continue to apply.

By signing electronically, I confirm that I reviewed this agreement, had an opportunity to ask questions, and agree to the items contained in this document.

SimplePractice records my electronic signature and date. Each participating adult signs their own copy.

Ehsan Adib Shabahang countersigns electronically, with the date recorded.

Practice forms and privacy information: atreef.com/privacy-policy

Download fees and billing form (PDF)

Credit and Debit Card and Payment Authorization

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

Only the person whose card will be kept on file (the cardholder) signs this form. If you will not keep a card on file, do not sign this form.

Purpose

This authorization allows AtReef Therapy, PLLC to keep a payment card on file and charge it only as described below. The Financial and Billing Agreement and, for assessment services, the Assessment Services Agreement state the applicable fees and policies. This form authorizes payment; it does not authorize treatment or change those agreements.

This form does not authorize AtReef Therapy, PLLC to charge a balance billed by a health plan, billing platform, or other third party because a claim was denied or that party could not collect. A direct-billing arrangement must be confirmed before AtReef Therapy, PLLC charges the card for a service. The same amount will not be collected more than once.

This authorization applies to charges for services I receive and, if I have separately agreed in writing to pay for another person’s services, those charges too.

Card on file

Enter your card directly in the SimplePractice client portal. Do not send card numbers by email or write them on this form. SimplePractice and its payment processor handle the card information entered in the portal. AtReef Therapy, PLLC staff may use the payment information needed for authorized billing tasks.

You may use an HSA or FSA card. You are responsible for determining whether a charge qualifies under your account’s rules. Please keep a valid card on file and update it before it expires.

Charges authorized

By signing, you authorize AtReef Therapy, PLLC to charge the card on file for the following, when applicable:

  • Direct-billed session fees for services covered by the applicable Financial and Billing Agreement or Assessment Services Agreement, at the agreed fee. Session charges may be processed on the session date.
  • A late-cancellation or missed-session fee, only when it applies under the applicable Financial and Billing Agreement or Assessment Services Agreement.
  • A specific balance or other charge only after AtReef Therapy, PLLC identifies the amount and you approve that charge in writing.
  • An assessment fee covered by a written assessment quote you approve.

This authorization does not itself change any fee. Fee changes are governed by the applicable Financial and Billing Agreement or Assessment Services Agreement. AtReef Therapy, PLLC will not charge more than the applicable agreed fee or a specific amount you separately approve in writing.

Charges that need separate approval

Additional professional work, legal work, testimony, and assessment services are not authorized by this form unless you separately approve the specific charge in writing. For assessment services, approval of the written quote is approval of the quoted amount and scope.

If you pay for someone else

If your card will pay for another person’s services, you must have separately agreed in writing to be financially responsible for those charges. Paying for another person’s care does not give you access to that person’s records or information about their care.

Receipts and statement description

AtReef Therapy, PLLC will provide a receipt for each charge through the client portal or by email. Charges may appear on your statement as ATREEF THERAPY. Your bank or card issuer may shorten or change the displayed name.

Declined charges, errors, and disputes

If a charge is declined, AtReef Therapy, PLLC will notify you so you can update the card or discuss another permitted payment arrangement. Any scheduling decisions are governed by the applicable practice policies and law, with attention to safety and continuity of care.

If you believe a charge is incorrect, you may contact AtReef Therapy, PLLC at (617) 906-6767 or ehsan@therapysecure.com. AtReef Therapy, PLLC will review the concern. If AtReef Therapy, PLLC confirms an error, it will initiate a refund to the original card within 5-7 business days; the card issuer controls when the credit appears in your account. Contacting AtReef Therapy, PLLC first is not required and does not limit any rights you may have with your card issuer.

Duration and cancellation

This authorization remains in effect until you cancel it. You may cancel it at any time by notifying AtReef Therapy, PLLC in writing. If SimplePractice offers a card-removal feature, removing the card alone may not notify AtReef Therapy, PLLC; please also contact the practice. Cancellation stops future charges under this authorization, except transactions already initiated before the practice received your cancellation. Amounts lawfully owed remain payable through another permitted arrangement; an unpaid balance does not authorize new charges to a card after authorization is canceled.

If you cancel this authorization, contact AtReef Therapy, PLLC to discuss another permitted payment arrangement. Any scheduling decisions are governed by the applicable practice policies and law, with attention to safety and continuity of care.

This form authorizes charges to the card entered in SimplePractice only. It does not authorize ACH or other bank-account transfers. Any recurring debit-card or bank-account debit arrangement requires the additional authorization, notices, and copy required by applicable law.

By signing electronically, I confirm that I reviewed this agreement, had an opportunity to ask questions, and agree to the items contained in this document.

SimplePractice records my electronic signature and date. Each participating adult signs their own copy.

Ehsan Adib Shabahang countersigns electronically, with the date recorded.

Practice forms and privacy information: atreef.com/privacy-policy

Download payment card authorization form (PDF)

Private-Pay Agreement and Insurance Election

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

This agreement records your choice to pay directly for the services and fees confirmed in your written arrangement.

Payment choice

I choose to pay AtReef Therapy, PLLC directly for the services, fees, and effective date or service period confirmed in my Financial and Billing Agreement or written fee arrangement. AtReef Therapy, PLLC will not submit insurance claims for those services. Payment and cancellation terms follow my Financial and Billing Agreement and any applicable assessment agreement.

Insurance

If I have commercial health insurance, I voluntarily choose not to have AtReef Therapy, PLLC bill it for these services. I understand covered care may cost me less and may ask my plan about benefits before deciding. Reimbursement is not guaranteed, and charges may not count toward my deductible or out-of-pocket limit. I am responsible for seeking any permitted reimbursement and may request an itemized statement or superbill, subject to applicable requirements.

Limits and changes

This arrangement applies only where permitted by law and applicable payer or platform agreements. Signing does not transfer services from Alma, Grow Therapy, Headway, or another platform or replace required payer, platform, or public-program documents. I disclose Medicare, Medicaid, or other public-program coverage before services begin.

I may end this election for future services by notifying the practice in writing before my next appointment. Any new billing arrangement must be confirmed before further services; insurance billing is not guaranteed. Earlier services retain their original arrangement.

A Good Faith Estimate is provided separately when required; this agreement does not waive related dispute rights. Privacy rights and requests to limit health-plan disclosures follow the Notice of Privacy Practices.

By signing electronically, I confirm that I reviewed this agreement, had an opportunity to ask questions, and agree to the items contained in this document.

SimplePractice records my electronic signature and date. Each participating adult signs their own copy.

Ehsan Adib Shabahang countersigns electronically, with the date recorded.

Practice forms and privacy information: atreef.com/privacy-policy

Download private-pay election form (PDF)

Optional AI and recordings

Authorization to Share Recordings with a Gottman Consultant

AtReef Therapy, PLLC

Dr. Ehsan Adib Shabahang, MA, PhD, LMHC, LPC, LCMHC, NCC

Version 3.5 | Effective October 20, 2026

This form explains sharing session recordings for Gottman consultation and certification review.

What will be shared

As a primary tool in Gottman Method Couples Therapy, and in order to augment your therapy work, I sometimes use videotape feedback as part of therapy sessions. This means that I may ask to videotape you during specific dialogues or exercises, or during entire sessions.

In addition to in-session use, I may wish to use the videotapes to receive consultation from Drs. John or Julie Gottman or an independently practicing clinician (called a “Consultant”) who has received training from The Gottman Institute. As a clinician trying to earn the distinction of “Gottman Certified Therapist,” the use of videotape allows for more effective peer feedback and education, as well as assurance of a higher quality of care in the therapy sessions. This consultation may occur during the time of treatment or thereafter (the certification process lasts 2 years). During this process, your name will be kept strictly confidential.

In addition, all matters discussed in consultations will remain completely confidential between myself and my Gottman Institute Consultant, and within The Gottman Institute staff.

The videotapes are not part of your clinical record and will not be used for any other purpose without your written permission. Further, they will be erased when they are no longer needed for these purposes.

These tapes are my property and will remain solely in my possession during the course of your therapy. Copies may be sent to The Gottman Institute for the purposes noted above. Should you wish to review these tapes for any reason, we will arrange a session to do so. These materials will remain in locked facilities at all times.

Your acknowledgment

I understand and accept the conditions of this statement and give my permission to have my therapy sessions videotaped or digitally recorded. I understand I may revoke this permission in writing at any time but until I do so it shall remain in full force and effect until the purposes stated above are completed.

Practice forms and privacy information: atreef.com/privacy-policy

Download sharing recordings form (PDF)

Using this website

Website Privacy Policy

How information is handled when you visit atreef.com or contact the practice through the website.

Updated .

This policy applies to the public website of AtReef Therapy, PLLC. My Notice of Privacy Practices explains how I handle protected health information and your rights concerning that information. Website information that is protected health information is handled under the applicable privacy requirements.

Information you provide

If you use a website form or contact the practice, I receive the information you provide, such as your name, contact details, and message. I use it to respond, manage inquiries, coordinate services, and meet applicable obligations. Please use the client portal for sensitive clinical information and payment details.

If you choose to subscribe to practice updates or educational emails, the information you provide may be used for that purpose. You can unsubscribe from those optional communications.

Website activity and technical information

This website is hosted by Squarespace. Visiting the site may involve processing technical information such as an IP address, browser and device information, pages visited, referring pages, and the time of a visit. This information may be used to deliver website features, understand site use, maintain security, and measure website or advertising performance.

Cookies, analytics, and advertising tools

The website uses cookies and similar technologies. Its current configuration includes Squarespace services, Google Analytics, Google Tag Manager, and Meta Pixel. These tools have different purposes:

  • Squarespace: website hosting, website features, cookie preferences, and site analytics.
  • Google Analytics: measurement of website visits and interactions, including browser, device, and page activity information.
  • Google Tag Manager: management and delivery of website tags; the information processed depends on the tags configured through it.
  • Meta Pixel: measurement of website visits and advertising activity. Meta may receive website activity and technical identifiers and may connect that activity with information it already holds, subject to its policies and applicable settings.

Depending on the tool, configuration, and your choices, information may be processed by the relevant provider. For details, see the Squarespace Privacy Policy, Google’s information about partner websites, and Meta Privacy Policy.

Your website privacy choices

Use the Accept or Decline options in the website’s cookie banner to choose optional cookies. If a saved cookie-preferences control is displayed, you can use it to revisit those choices. You can also manage cookies through your browser. Blocking some cookies may affect website features.

Provider controls include Google’s Analytics opt-out browser add-on and privacy or advertising settings in your Google and Meta accounts. These controls apply to their respective services and do not replace any privacy rights available under applicable law.

Client portal and outside platforms

Links may take you to SimplePractice or another outside service for scheduling, forms, billing, or other functions. Those services have their own privacy notices and account settings. My responsibilities for information I handle continue to apply as described in the Notice of Privacy Practices and applicable law.

Sharing, retention, and security

Website and communication providers may process information within their service roles. Information may also be disclosed when permitted or required by law. The analytics and advertising tools described above may involve disclosure of website activity to their providers.

I retain website correspondence and administrative information as reasonably needed to respond, operate the practice, and meet applicable legal obligations. Health information follows applicable clinical record-retention requirements.

I use reasonable safeguards appropriate to the information and the service. No electronic system or transmission is completely secure. Avoid sending sensitive information through ordinary website messages, email, or social media when the client portal is available.

Questions, requests, and changes

You may contact me about personal information you submit through the website or to ask about access, correction, deletion, or other rights that apply to you. I may need to verify your identity. Legal and record-retention requirements may limit a request. Health-record requests follow the Notice of Privacy Practices.

The practice provides services for adults. If you believe a child has submitted personal information through the website, contact me so I can review it.

I may update this website policy as the website or its practices change. The date above and the updates section identify the current published information. Any additional notice required by law will be provided.

Keeping you informed

Policy & form updates

Current versions, effective dates, and changes to practice documents.

Effective date

Practice forms, Version 3.5

The eleven practice documents on this page carry Version 3.5 and an effective date of October 20, 2026. The privacy notice appears above; the other documents are grouped by their purpose.

What you need to do: Review the documents that apply to your services and complete any forms I send through the client portal. Contact me if you have a question before signing.

Review the current forms

When a document changes, I will identify the affected form, its new version and effective date, the main changes, and any action needed. If a change requires direct notice or renewed consent, I will provide it separately.

The Financial and Billing Agreement provides for at least 30 days’ written notice before changes to fees or financial policies. Posting information here does not record your agreement to a change.

Questions & requests

A question about your privacy?

You can ask about a form, your information, or a privacy concern.

Where do I sign my forms?

I send the forms that apply to you through the SimplePractice client portal. The documents on this page are reference copies. Each participating adult completes their assigned forms separately.

Can I decline AI-assisted documentation?

Yes. Under the AI consent form, participation is optional. Declining does not affect your access to care or the quality of your treatment. You may also ask me to pause or stop a tool or withdraw consent as described in the form.

Are therapy sessions recorded?

AI transcription, retained session recordings, and sharing recordings are separate activities. Each requires the applicable consent or authorization described in the relevant form. Signing a general treatment consent does not authorize all three. See the AI consent, couples recording consent, and recording-sharing authorization.

How do I request my records or raise a privacy concern?

Contact me as Privacy Officer using the details below. The privacy notice explains record-access rights, identity verification, and applicable deadlines. You may also file a privacy complaint as described in that notice.

How will I hear about changes?

The updates section identifies published versions and effective dates. I will provide any required direct notice or updated consent separately. Your assigned portal documents record the forms you are asked to review or sign.