Acknowledgement and Consent to Use Electronic Communication

I have been advised and understand that the use of email, cell phone texting, and other forms of technology in psychotherapy/coaching has not been defined as a best-practice strategy. I have also been specifically advised of the following:

1. Email/texting communication with my therapist/coach will be used for the purpose of simplifying and expediting scheduling/administrative matters only.

2. Email/texting communication is NOT to be used to provide/receive treatment services or take the place of therapy/coaching sessions. Therefore, email/texting should NOT be used to communicate: Suicidal or homicidal thoughts or plans Urgent or emergency issues Serious or severe side effects or concerns Rapidly worsening symptoms

3. In a life-threatening emergency, patients/clients should:

• Call 911
• Proceed to the nearest hospital emergency room
• Call a crisis hotline such as 1-800-273-8255 (phone number active as of July 22, 2019)

4. Any information exchanged electronically or with the use of technology increases the risk of confidentiality breaches. No technology is 100% secure and the therapist/coach cannot guarantee protection from unauthorized attempts to access, use, or disclose personal information exchanged electronically.

5. Email/cell phone texting is not a reliable way of obtaining urgent help from the therapist/coach in an emergency.

6. E-mail encryption is used to communicate sensitive information, but may not be used in all email exchanges, which is why session content and electronic protected health information should not be shared via email.

7. Sessions may be conducted via telephonic or video platform. These technologies are not assured to be completely confidential, though all efforts will be made to ensure HIPAA compliance for therapy patients.

If any provision of this agreement, or any application of any provision of this agreement, is held to be invalid, or to violate or be inconsistent with any federal law or regulation, that shall not affect the validity or effectiveness of any other provision of this agreement, or of any other application of any provision of this agreement, which can be given effect without that provision or application; and to that end, the provisions and applications of this agreement are severable. I have thoroughly considered all of the above information, and I have obtained whatever additional input and/or professional advice I deem necessary in making an informed decision regarding email/texting communication.

By signing below, I consent to the use of email/cell phone texting within the guidelines above. If more urgent help is needed, I will utilize the crisis services listed above in section 3. Furthermore, my therapist/coach may in the future advise a restriction on electronic communication for security or treatment purposes.