Client Email/texting Informed Consent Form printable pdf download

Dr. Barbara Cunningham

2835 Camino Del Rio South, Ste. 120-C

San Diego, CA 92108

Client Email/Texting Informed Consent Form

1. Risk of using email/texting

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:

a. Email and texts can be circulated, forwarded, stored electronically and on paper, and

broadcast to unintended recipients.

b. Email and text senders can easily misaddress an email or text and send the information to

an undesired recipient.

c. Backup copies of emails and texts may exist even after the sender and/or the recipient has

deleted his or her copy.

d. Employers and on-line services have a right to inspect emails sent through their company

systems.

e. Emails and texts can be intercepted, altered, forwarded or used without authorization or

detection.

f. Email and texts can be used as evidence in court.

g. Emails and texts may not be secure 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 texts

Therapist cannot guarantee but will use reasonable means to maintain security and

confidentiality of email and text information sent and received. Therapist is not liable for

improper disclosure of confidential information that is not caused by Therapist’s intentional

misconduct. Clients/Parent’s/Legal Guardians must acknowledge and consent to the following

conditions:

a. 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.

b. Email and texts should be concise. The client/parent/legal guardian should call and/or

schedule an appointment to discuss complex and/or sensitive situations.

c. All email will usually be printed and filed into the client’s medical record. Texts may be

printed and filed as well.

d. Provider will not forward client’s/parent’s/legal guardian’s identifiable emails and/or

texts without the client’s/parent’s/legal guardian’s written consent, except as authorized

by law.

e. Clients/parents/legal guardians should not use email or texts for communication of

sensitive medical information.

f. Provider is not liable for breaches of confidentiality caused by the client or any third

party.

g. It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an

appointment if warranted.

Client Email/texting Informed Consent Form