IMPORTANT NOTE: E-mail communication shall not be used in any situation in which there are clinical issues that need to be addressed or in any crisis or emergent situation, as it is quite possible that no one will receive or read an email for several days. If there is a crisis, contact must be made by means other than e-mail. Likewise, clinical issues should be discussed during a therapeutic contact and NOT via e-mail. Consent to Communication via E-Mail Name* First Last Date of Birth* Email* Enter Email Confirm Email I would like to (please check all that apply):* Utilize e-mail communication with my or my child/ward’s treatment provider(s) at Riverbend. Authorize Riverbend to utilize e-mail communication with my insurance company. Consent to the use of e-mail communications* I consent to the use of e-mail communications.I am aware of the policies relevant to the use of e-mail and of the fact that the confidentiality of such communications cannot be assured. I am also aware that e-mail is not to be used in crisis or emergent situations, nor to discuss clinical issues.Client Signature:Date MM slash DD slash YYYY Guardian's Signature (if applicable):Date MM slash DD slash YYYY
