Download the PDF version with the above link or use the form below to submit online
Online Form Submission
1. Risk of Using Email and Text Communication
The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:
- Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
- Emails and text senders can easily misaddress an email or text and send the information to an undesired recipient.
- Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
- Employers and online services have a right to inspect emails sent through their company systems.
- Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.
- Emails and texts can be used as evidence in court.
- Emails and texts should be assumed to be unencrypted and, therefore, it is possible that the confidentiality of such communications may be breached by a third party.
2. Conditions for the Use of Email and Text Communication
- Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
- Email and texts should be concise. The client/responsible party should call and/or schedule an appointment to discuss complex and/or sensitive situations.
- Emails may be printed and filed into the client’s medical record. Texts may be printed and filed as well
- Provider will not forward client’s/responsible party’s identifiable emails and/or texts without the client’s/responsible party’s written consent, except as authorized by law
- Clients/responsible parties should not use email or texts for communication of sensitive personal information
- Provider is not liable for breaches of confidentiality caused by the client/responsible party or any third party.
3. Client Acknowledgement and Agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication using email and/or texts between Psychological Associates of the Black Hill sand me, and consent to the conditions as outlined, as well as any other instructions that may be imposed to communicate with me by email or text.