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Communication by Email, Text Message,and Other Non-Secure Means

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.

The kinds of parties that may intercept these messages include, but are not limited to:
  • People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
  • Your employer, if you use your work email to communicate with Family Service Rochester
  • Third parties on the Internet such as server administrators and others who monitor Internet Traffic.

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 me the following protected health information:
  • Information related to the scheduling of meetings or other appointments
  • Responses to follow-up questions regarding services.

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:

  • Name, Address, and Phone Number-to arrange for requested services

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.

Name of Client *:
Date *:
E-Signature of Client or Legal Guardian *:

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