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It may become useful during the course of services to communicate by email, text message (e.g. "SMS) or other electronic methods of communication. If these methods are used to communicate with Family Service Rochester, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages.
If there are people in your life that you don't want accessing these communications, please talk with Family Service Rochester about ways to keep your communication safe and confidential.
By filling out the following form, I am consenting to allow Family Service Rochester to use unsecured email and mobile phone text messaging to transmit to Family Service Rochester Volunteers the following protected health information:
By filling out the following form, I am acknowledging that I have been informed of the risks, including but not limited to my confidentiality in services, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive requested services. I also understand that I may terminate this consent at any time.