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Consent to Communicate by Email and Text Message (SMS)

A Life In Balance DBT Skills Training Group

Authorization for Communication of Protected Health Information (PHI)

You may give permission to A Life in Balance (the “Company”) to communicate with you by unencrypted email and text message (SMS). The purpose of these communications is to send you group session schedules and reminders, to confirm appointments and intake steps, to check in periodically, and to share other information about the DBT Skills Training Program and related services you receive from the Company. This form explains the risks of these forms of communication, the conditions under which we use them, and documents your consent.

1.  Risks of using unencrypted email and text messages

Email and text messages carry a number of risks you should consider. These include, but are not limited to, the following:

a.    They can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

b.    They can be misaddressed and sent to an unintended recipient.

c.     Backup copies may continue to exist even after the sender and recipient have deleted their copies.

d.    Employers and online service providers may have a right to inspect messages sent through their systems.

e.    They can be intercepted, altered, forwarded, or used without authorization or detection.

f.      They can be obtained and used as evidence in court.

g.    Devices containing messages can be lost or stolen, resulting in disclosure to unauthorized individuals.


2.  Conditions for the use of email and text messages

The Company cannot guarantee, but will use reasonable means to maintain, the security and confidentiality of email and text information sent and received. You acknowledge and agree to the following:

a.    In a medical or mental health emergency, do not use email or text. Call 911, or call or text 988 (Suicide & Crisis Lifeline). Email and text are not monitored continuously and are not a substitute for crisis services or for contacting your individual therapist. Please relay urgent needs by telephone.

b.    Messages to us should not be time-sensitive. We aim to respond on business days but cannot guarantee that any message will be read or answered within a specific timeframe. If you have not heard back within three business days, please call our office to confirm we received your message.

c.     Please speak with your Company contact directly to discuss complex or sensitive matters rather than send them by email or text.

d.    Use your best judgment before sending sensitive health information by email or text. The Company and its personnel are not responsible for the content of messages you send to us.

e.    The Company is not liable for breaches of confidentiality caused by you or any third party.

f.      It is your responsibility to follow up with your Company contact when warranted.


3.  Withdrawal of consent

You may revoke this consent at any time by notifying the Company in writing. To stop text messages, reply STOP to any message. Revoking consent will not affect your participation in the DBT Skills Training Program, your ability to receive future care, or any benefits to which you are otherwise entitled.


4.  Acknowledgement and agreement

By providing my cell phone number and/or email address, I consent to receive unencrypted email and/or text messages at the contact information I provide. These messages may include information about my health and care, including group session schedules and reminders, appointment confirmations, intake steps, and other information about services I receive from the Company.


I understand that message and data rates from my mobile carrier may apply. To unsubscribe, reply STOP to any message. For help, text HELP to the same number at any time.


I have read and fully understand this form. I understand the risks of using unencrypted email and text messaging to communicate with the Company, and I consent to the conditions described, as well as any additional instructions the Company may set for communicating with me by email or text.

My Contact Preferences

By signing below, I consent to be contacted by both email and text message (SMS) at the phone number and email address I have provided above.

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