By filling out this form and selected an option below, I/We acknowledge I/we have read this document and have had the opportunity to ask questions. I/We hereby understand and accept the associated risks herein regarding the use of electronic communication methods in relation to Service(s) being rendered. I/We hereby consent to use of electronic communication to transmit my PHI.

Should I wish to withdraw my consent at any time, I understand that I must notify Kathy Roth, LCSW with Empowered Life, LLC, in writing of the withdrawal of my consent.

Electronic Communication
Empowered Life, LLC uses technology and electronic communication in a variety of manners during and throughout delivery of our services with client. These electronic communication methods include but are not limited to, email, text message, phone calls, video calls/conferencing, online meetings/webinars, online forms, and/or fax. These methods may be used with clients for purposes of initial outreach/intake, counseling services, education workshops, support groups, community resources and referrals, for service updates and/or changes, and/or to provide emotional support related to services being rendered.

Personal Health Information (PHI)
PHI is defined as information about you that may identify you and that relates to your past, present or future physical/mental health condition and related healthcare services. Empowered Life, LLC and its professionals strive to limit the use of PHI in electronic communication whenever possible to minimize risk to our clients. While Empowered Life, LLC takes the highest precautions to protect your PHI through various electronic communication we cannot guarantee privacy of your PHI, and thus must disclose this information as outlined in this Document as well as obtain your written authorization.

Benefits and Risks
There are many benefits to the use of technology and electronic communication including but not
limited to, enhancing access to services that otherwise may be unavailable, ease and convenience of service, reduction in client’s travel, and delivery of cost-effective services. There are also some risks to be aware of including but not limited to, potential for technology difficulty/failure and interruption in service, potential for confidentiality breach(es), and/or higher costs of technology. Furthermore, electronic communication does not have any guarantee of privacy, and that a third party may be able to access my protected health information (PHI). Risks can be further discussed in more detail with your professional prior to, or during services being rendered upon Client’s request.