CONSENT FOR NOTICE BY ELECTRONIC TRANSMISSION

CONSENT FOR NOTICE BY ELECTRONIC TRANSMISSION
Improving Lives Counseling Services, Inc. is now offering the option to receive notifications and billing statements via email instead of through the U.S. Postal service.
- To adopt email as your primary mode of notification, please complete this authorization
After providing authorization for electronic communication you can change or revoke your designation at any time by witing or emailing Improving Lives Counseling Services.

Improving Lives Counseling Services

6216 South Lewis Avenue Suite 102

Tulsa, Oklahoma 74136

Becca@ImprovingLivesCounseling.com
I hereby authorize Improving Lives Counseling Services (ILCS) to send all notifications and statements via email instead of through the U.S. Postal service. I understand that these emails may contain personal information such as names, addresses, and services received from ILCS. I also understand that these communications may not be secure. I agree that it will be my responsibility to notify ILCS of any changes to my email address listed below.
Client Name: *
Parent/Guardian Name:
Email Address 1 *
example@example.com
Email Address 2
example@example.com
Phone Number *

Area Code Phone Number
Please initial one of the following options and sign the bottom of the form.
I do not consent to receive notifications and statements electronically
I consent to receive electronic notifications and statements to the email address(es) listed above in the form of an unsecured PDF attachment
I consent to receive electronic notifications and statements to the email address(es) listed above in the form of a password protected PDF using the password listed below:
Client or Parent/Guardian Signature *

Clear
Date: *

Month Day Year
Date
Should be Empty: