Email Consent Form

Before authorizing email communication, we wanted to make you aware of the following points:

1. Email communication between you and your therapist is not secure unless it is encrypted.
2. We will encrypt our email communication to you unless you tell us that you prefer to use
unencrypted email. If you prefer that we not encrypt our email communications to you, please initial here: INITIALS

Encrypted email: Email content is protected by password. Your provider will either 1) type content in a password-protected Word attachment, or 2) you will be asked to log into a secure system to view email content.

Unencrypted email: Content is not password protected. Email will show up as usual.

WashU email (students and employees): Emails between @wustl.edu email addresses are automatically encrypted, but may be visible to the University. If you would like your communications to be confidential from WashU, please provide a NON- @wustl.edu email address.

3. If you elect to email from your workplace computer, your employer and its agents may have access to those email communications.
4. Email communications may become a part of your PSC clinical record and be accessible to the PSC support staff as needed for our operations.

Because of these issues, email may be a useful way to complete scheduling or provide therapeutic materials, but should not be used to communicate personal information. Email will not be used to conduct therapy. EMAIL COMMUNICATION SHOULD NEVER BE USED IN THE CASE OF AN EMERGENCY OR FOR URGENT REQUESTS FOR INFORMATION.

If you chose to authorize email communication, please understand that incoming emails will be reviewed and answered as soon as possible. If you have not received a response in a reasonable amount of time or are concerned your therapist may not have received the message, please call the office during regular business hours (314-935-6555).

This authorization may be revoked at any time and must be done in writing. It is understood that the revocation will not apply to information that has already been released based on this authorization.

If you agree to the foregoing terms, please indicate your acceptance by your signature that you understand and accept the terms and conditions outlined herein.

ACCEPTED: Signature of Individual*

Name of Individual*

First NameLast Name

Authorized Email of Individual*

example@example.com

I consent to WashU encryption as described above. I understand that my communications may be visible to WashU.

Last 4 digits of phone number (we'll use this as the password protecting your email attachments):*

Last 4 Digits of Phone Number

Date of Signing*

Name of Therapist (if assigned)

AUTHORIZATION TO UTILIZE UNENCRYPTED EMAIL TO COMMUNICATE PROTECTED HEALTH INFORMATION