Consent to Non-Secure Forms of Electronic Communication

Electronic communication, via email and text, between you and your therapist may not be secure. By signing below, you are acknowledging: 

  • Email and text communication does not provide a completely secure means of communication. 
  • While your therapist will take reasonable efforts to protect your confidentiality, there is some risk that any protected health information contained in email or text may be disclosed to or intercepted by unauthorized third parties.
  • Your treatment will not depend on you giving consent. 
  • You have the right to terminate this agreement at any time.
  • Use of more secure communications, such as phone or end-to-end encrypted emails with identity verification, are always an alternative that are available to you if you elect to not give consent to the following forms of communication.

Sign in to Google to save your progress. Learn more
Email *
I give permission for my therapist to contact me using the following non-secure methods regarding reminders, scheduling, or other relevant matters, and I understand the risks involved: (check all that apply) *
Required
*
Required
Type your name below:  *
Today's Date
 *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Springs Therapy. Report Abuse
Google Forms