Intake Forms


Electronic Communication Informed Consent

    CLIENTS MUST CONSENT TO THE USE OF ELECTRONIC COMMUNICATION FOR CONFIDENTIAL MEDICAL INFORMATION AFTER HAVING BEEN INFORMED OF THE FOLLOWING:

    • Electronic communication cannot be guaranteed for the following risk factors:
      Can be immediately broadcast worldwide and received by many intended and unintended recipients
    • Can be forwarded to other recipients without the original sender's permission or knowledge
    • Can be falsified more easily than written or signed documents
    • Can be easily misaddressed
    • Back up copies of electronic communication may exist even after the sender or recipient has deleted the information

    CONSENT TO THE USE OF ELECTRONIC COMMUNICATION FOR CONFIDENTIAL MEDICAL INFORMATION INCLUDES AGREEMENT WITH THE FOLLOWING CONDITIONS:

    • The therapist and client will agree upon the appropriate use of electronic communication. If it is used inappropriately Brill Counseling will not allow electronic communication as an option.
    • All electronic communication concerning diagnosis and/or treatment will be printed out and made a part of the client's case record
    • Caution should be used in conveying sensitive/personal information due to security risks.
    • Clients do not have a right to privacy in their employer's email system, so should not use that system to transmit confidential information.
    • Clients who have consented to use electronic communication are responsible for informing their therapist of any type of information they do not want sent in this format.
    • Promptness in responding to electronic communication cannot be guaranteed. If you need an immediate response, use our phone system.
    • EMERGENCIES cannot be handled through electronic communication. In the case of an emergency please dial 911 or go to your nearest emergency room. For urgent matters please leave a telephone message.
    • This consent is valid for the entire course of treatment and may be withdrawn, in writing, at any time

    Signature