Common use of Mobile Phone Communication Clause in Contracts

Mobile Phone Communication. Please note that if we communicate via my mobile phone by voice or text, your phone number will be stored in the phone!s memory for a period of time and therefore if my mobile phone is lost or stolen, it is theoretically possi- ble that your contact information might be accessed. Note that my mobile phone is password and thumbprint protected. Email Communication. If you elect to communicate with me by email, please be aware that email is not completely confidential. All emails are retained in the logs of your and/ or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be considered part of your treatment record. Please be aware that I regularly access email communications via my password-protected mobile phone. It is theoreti- cally possible that if my mobile phone is lost or stolen and the password is somehow circumvented, our email communications could be accessed. If there is a reason for billing or other Protected Health Information to be sent to you via email, I will use an email service that is HIPAA-compliant with built-in encryption. By signing below, I am giving consent for communications via (please provide a check): Telehealth sessions • If Telehealth is wanted or needed, we agree to the use of a HIPAA compliant video-conferencing platform selected for our virtual sessions, and the psycholo- gist will explain how to use it. • Confidentiality still applies for Telehealth services. • You need to use a webcam or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your tele-appoint- ment, you must notify Xx. Xxxx X'Leary in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. • As your psychologist, I may determine that due to certain circumstances, Tele- health is no longer appropriate and that we should resume our sessions in-per- son. Please check all that apply: Telehealth Email Phone Signature _ Printed name Date Phone number I, Xxxx O!Xxxxx, PhD, have met with this client and have informed him or her of the is- sues and points raised in this statement of introduction to my therapy practice. I have responded to all of his or her questions. I believe this person fully understands the is- sues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my sig- nature here. Xxxx X X’Xxxxx PhD Date Your emergency contact: Emergency contact: Relationship:

Mobile Phone Communication. Please note that if we communicate via my mobile phone by voice or text, your phone number will be stored in the phone!s phone’s memory for a period of time and therefore if my mobile phone is lost or stolen, it is theoretically possi- ble that your contact information might be accessed. Note that my mobile phone is password and thumbprint protected. Email Communication. If you elect to communicate with me by email, please be aware that email is not completely confidential. All emails are retained in the logs of your and/ or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be considered part of your treatment record. Please be aware that I regularly access email communications via my password-protected mobile phone. It is theoreti- cally possible that if my mobile phone is lost or stolen and the password is somehow circumvented, our email communications could be accessed. If there is a reason for billing or other Protected Health Information to be sent to you via email, I will use an email service that is HIPAA-compliant with built-in encryption. By signing below, I am giving consent for communications via (please provide a check): via: Email: Phone: Telehealth sessions • If Telehealth is wanted or needed, we agree to the use of a HIPAA compliant video-conferencing platform selected for our virtual sessions, and the psycholo- gist will explain how to use it. • Confidentiality still applies for Telehealth services. • You need to use a webcam or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your tele-appoint- ment, you must notify Xx. Xxxx X'Leary in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. • As your psychologist, I may determine that due to certain circumstances, Tele- health is no longer appropriate and that we should resume our sessions in-per- son. Please check all that apply: Telehealth Email Phone Signature _ Printed name Name Date Phone number I, Xxxx O!XxxxxX’Xxxxx, PhD, have met with this client for a suitable period of time, and have informed him or her of the is- sues issues and points raised in this statement of introduction to my therapy practice. I have responded to all of his or her questions. I believe this person fully understands the is- suesissues, and I find no reason to believe this person is not fully competent com- petent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my sig- nature signature here. Xxxx X X’Xxxxx PhD Date Your emergency contact: Emergency contact: Relationship:

Mobile Phone Communication. Please note that if we communicate via my mobile phone by voice or text, your phone number will be stored in the phone!s phone’s memory for a period of time and therefore if my mobile phone is lost or stolen, it is theoretically possi- ble possible that your contact information might be accessed. Note that my mobile phone is password and thumbprint protected. Email Communication. If you elect to communicate with me by email, please be aware that email is not completely confidential. All emails are retained in the logs of your and/ or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be considered part of your treatment record. Please be aware that I regularly access email communications via my password-protected mobile phone. It is theoreti- cally theoretically possible that if my mobile phone is lost or stolen and the password is somehow circumvented, our email communications could be accessed. If there is a reason for billing or other Protected Health Information to be sent to you via email, I will use an email service that is HIPAA-compliant with built-in encryption. By signing below, I am giving consent for communications via (please provide a check): Telehealth via: Email: Phone: Tele-psychology sessions • If Telehealth tele-psychology is wanted or needed, we agree to the use of a HIPAA compliant video-conferencing platform selected for our virtual sessions, and the psycholo- gist psychologist will explain how to use it. • Confidentiality still applies for Telehealth tele-psychology services. • You need to use a webcam or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your tele-appoint- menttele- appointment, you must notify Xx. Xxxx X'Leary the psychologist in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. • As your psychologist, I may determine that due to certain circumstances, Tele- health telepsychology is no longer appropriate and that we should resume our sessions in-per- sonperson. Please check all that applyTelehealth Signature: Telehealth Email Phone Signature _ Signature: Printed name Date Phone number Name: Printed Name: Date: Date: I, Xxxx O!XxxxxX’Xxxxx, PhD, have met with this client for a suitable period of time, and have informed him or her of the is- sues issues and points raised in this statement of introduction to my therapy practice. I have responded to all of his or her questions. I believe this person fully understands the is- suesissues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my sig- nature signature here. Xxxx X X’Xxxxx PhD Date Your emergency contact: Emergency contact: Relationship:.

Mobile Phone Communication. Please note that if we communicate via my mobile phone by voice or text, your phone number will be stored in the phone!s memory for a period of time and therefore if my mobile phone is lost or stolen, it is theoretically possi- ble that your contact information might be accessed. Note that my mobile phone is password and thumbprint protected. Email Communication. I use a HIPAA-compliant Google email: mary@xxxxxxxxxxxxx@xxxxx.xxx. That said, If you elect to communicate with me by email, please be aware that email is I cannot completely confidential. All emails are retained in the logs guaran- tee complete confidentiality of your and/ or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be considered part of your treatment record. Please be aware that I regularly access email communications via my password-protected mobile phone. It is theoreti- cally possible that if my mobile phone is lost or stolen and the password is somehow circumvented, our email communications could be accessed. If there is a reason for billing or other Protected Health Information to be sent to you via all email, I will use an email service that is HIPAA-compliant with built-in encryption. By signing below, I am giving consent for communications via (please provide a check): Telehealth sessions • If Telehealth is wanted or needed, we agree to the use of a HIPAA compliant video-conferencing platform on Zoom selected for our virtual sessions, and the psycholo- gist I will explain how to use it. • Confidentiality still applies for Telehealth services. • You need to use a webcam or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your tele-appoint- ment, you must notify Xx. Xxxx X'Leary in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. • As your psychologist, I may determine that due to certain circumstances, Tele- health is no longer appropriate and that we should resume our sessions in-per- son. Please check all that apply: Telehealth Email Phone Signature _ Printed name Date Phone number I, Xxxx O!Xxxxx, PhD, have met with this client and have informed him or her of the is- sues and points raised in this statement of introduction to my therapy practice. I have responded to all of his or her questions. I believe this person fully understands the is- sues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my sig- nature here. Xxxx X X’Xxxxx PhD Date Your emergency contact: Emergency contact: Relationship:

Mobile Phone Communication. Please note that if we communicate via my mobile phone by voice or text, your phone number will be stored in the phone!s phone’s memory for a period of time and therefore if my mobile phone is lost or stolen, it is theoretically possi- ble that your contact information might be accessed. Note that my mobile phone is password and thumbprint protected. Email Communication. If you elect to communicate with me by email, please be aware that email is not completely confidential. All emails are retained in the logs of your and/ or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be considered part of your treatment record. Please be aware that I regularly access email communications via my password-protected mobile phone. It is theoreti- cally possible that if my mobile phone is lost or stolen and the password is somehow circumvented, our email communications could be accessed. If there is a reason for billing or other Protected Health Information to be sent to you via email, I will use an email service that is HIPAA-compliant with built-in encryption. By signing below, I am giving consent for communications via (please provide a check): Telehealth sessions • If Telehealth is wanted or needed, we agree to the use of a HIPAA compliant video-conferencing platform selected for our virtual sessions, and the psycholo- gist will explain how to use it. • Confidentiality still applies for Telehealth services. • You need to use a webcam or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your tele-appoint- ment, you must notify Xx. Xxxx X'Leary in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. • As your psychologist, I may determine that due to certain circumstances, Tele- health is no longer appropriate and that we should resume our sessions in-per- son. Please check all that apply: Telehealth Email Phone Signature _ Printed name Date Phone number I, Xxxx O!XxxxxX’Xxxxx, PhD, have met with this client and have informed him or her of the is- sues and points raised in this statement of introduction to my therapy practice. I have responded to all of his or her questions. I believe this person fully understands the is- sues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my sig- nature here. Xxxx X X’Xxxxx PhD Date Your emergency contact: Emergency contact: Relationship: