Common use of Hello Clause in Contracts

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-Show appointment fees will apply if I cancel my appointment with less than 48 hours’ notice. Appointment information is “Protected Health Information” under HIPAA. By signing, I give my permission to receive appointment reminders as selected. My signature indicates that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicable. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAME: DATE OF BIRTH: EMAIL ADDRESS: Care and Counseling will use reasonable means to protect the confidentiality of Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  Email can be copied, circulated, forwarded, and stored in electronic files;  Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  Email is easier to falsify than handwritten or signed documents;  Backup copies of email may exist even after the provider or client has deleted his or her own copy;  Employers and online services may have a right to archive and inspect emails transmitted through their systems;  Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  Email can be intercepted, altered, forwarded, or used without written authorization or detection;  Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a method of email communication, you acknowledge and agree to the following:  I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  I understand that I may, at any time, revoke my consent for email communications.  Unless revoked in writing, this authorization will expire upon the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE I request that my provider no longer use email to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-Show appointment fees will apply if I cancel my appointment with less than 48 hours’ notice. Appointment information is “Protected Health Information” under HIPAA. By signing, I give my permission to receive appointment reminders as selected. My signature indicates that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicable. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAMEClient Information Client Name: DATE OF BIRTHDate of Birth: EMAIL ADDRESSEmail Address: Care and Counseling will use reasonable means to protect the confidentiality of Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  • Email can be copied, circulated, forwarded, and stored in electronic files;  • Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  • Email is easier to falsify than handwritten or signed documents;  • Backup copies of email may exist even after the provider or client has deleted his or her own copy;  • Employers and online services may have a right to archive and inspect emails transmitted through their systems;  • Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  • Email can be intercepted, altered, forwarded, or used without written authorization or detection;  • Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a method of email communication, you acknowledge and agree to the following:  • I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  • I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  • I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  • I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  • I understand that I may, at any time, revoke my consent for email communications.  • Unless revoked in writing, this authorization will expire upon the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE Right to Revoke I request that my provider no longer use email to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) Notice of Privacy Practices 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, • xxx.xxxxxxxxxxxxxxxxx.xxx This notice describes how medical information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services about you may be used for diagnosis, treatment, follow-up and/or educationand disclosed and how you can get access to this information. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Providerreview it carefully.

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-No Show appointment fees will apply if I cancel my appointment with less than 48 hours’ noticestill apply. Appointment information is considered to be “Protected Health Information” under HIPAA. By signingmy signature, I give am giving my permission to receive appointment reminders as selectedI have noted above. My signature below indicates that I represent and warrant that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicableservices. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAME: DATE OF BIRTH: EMAIL ADDRESS: Care and Counseling will use reasonable means to protect the confidentiality of and disclose Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) ). Care and Counseling will use reasonable means to protect the confidentiality of PHI sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications communications, and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  Email can be copied, circulated, forwarded, and stored in electronic files;  Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  Email is easier to falsify than handwritten or signed documents;  Backup copies of email may exist even after the provider or client has deleted his or her own copy;  Employers and online services may have a right to archive and inspect emails transmitted through their systems;  Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  Email can be intercepted, altered, forwarded, or used without written authorization or detection;  Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a By authorizing the above method of email communication, you acknowledge and agree to the following:  I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  I understand that I may, at any time, revoke my consent for email communications.  Unless revoked in writing, this authorization will expire upon the later of the following events: 1) one (1) year after the date of my signature, or 2) the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE I request that my provider no longer use email to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.Date

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-No Show appointment fees will apply if I cancel my appointment with less than 48 hours’ noticestill apply. Appointment information is considered to be “Protected Health Information” under HIPAA. By signingmy signature, I give am giving my permission to receive appointment reminders as selectedI have noted above. My signature below indicates that I represent and warrant that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicableservices. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAME: DATE OF BIRTH: EMAIL ADDRESS: Care and Counseling will use reasonable means to protect the confidentiality of and disclose Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) ). Care and Counseling will use reasonable means to protect the confidentiality of PHI sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications communications, and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  Email can be copied, circulated, forwarded, and stored in electronic files;  Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  Email is easier to falsify than handwritten or signed documents;  Backup copies of email may exist even after the provider or client has deleted his or her own copy;  Employers and online services may have a right to archive and inspect emails transmitted through their systems;  Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  Email can be intercepted, altered, forwarded, or used without written authorization or detection;  Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a By authorizing the above method of email communication, you acknowledge and agree to the following:  I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  I understand that I may, at any time, revoke my consent for email communications.  Unless revoked in writing, this authorization will expire upon the later of the following events: 1) one (1) year after the date of my signature, or 2) the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE I request that my provider no longer use email to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) C:\Users\jalexander\AppData\Local\Temp\7496-2794-c8a3-7f10.docx 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-No Show appointment fees will apply if I cancel my appointment with less than 48 hours’ noticestill apply. Appointment information is considered to be “Protected Health Information” under HIPAA. By signingmy signature, I give am giving my permission to receive appointment reminders as selectedI have noted above. My signature below indicates that I represent and warrant that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicableservices. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAME: DATE OF BIRTH: EMAIL ADDRESS: Care and Counseling will use reasonable means to protect the confidentiality of and disclose Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) ). Care and Counseling will use reasonable means to protect the confidentiality of PHI sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications communications, and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  • Email can be copied, circulated, forwarded, and stored in electronic files;  • Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  • Email is easier to falsify than handwritten or signed documents;  • Backup copies of email may exist even after the provider or client has deleted his or her own copy;  • Employers and online services may have a right to archive and inspect emails transmitted through their systems;  • Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  • Email can be intercepted, altered, forwarded, or used without written authorization or detection;  • Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a By authorizing the above method of email communication, you acknowledge and agree to the following:  • I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  • I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  • I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  • I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  • I understand that I may, at any time, revoke my consent for email communications.  • Unless revoked in writing, this authorization will expire upon the later of the following events: 1) one (1) year after the date of my signature, or 2) the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE I request that my provider no longer use email to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.

Hello. This is a reminder of your appointment on Monday, January 11, scheduled for 4 PM with Name of Counselor. If you need to reschedule or have any questions, feel free to call us at (000) 000-0000. Once again, your appointment is scheduled for Monday, January 11, at 4 PM with Name of Counselor. Thank you. Phone number for the automated system to call: ( ) - Email message: I authorize Care and Counseling to send an email message appointment reminders to me on my provided email address. Example of email message from XxxxxxXxxxXxxxxxxx@xxxxxxxxXxxxxxx.xxx This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor. If you have any questions regarding your appointment, please feel free to contact us at: (000) 000-0000. Thank you. Email address(es) to send reminder messages to (up to 2): None of the above: I will remember my appointments on my own. I understand that Late Cancellation and No-No Show appointment fees will apply if I cancel my appointment with less than 48 hours’ noticestill apply. Appointment information is considered to be “Protected Health Information” under HIPAA. By signingmy signature, I give am giving my permission to receive appointment reminders as selectedI have noted above. My signature below indicates that I represent and warrant that I am the person legally responsible for all use of the accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services if applicableservices. I understand that this authorization can only be revoked in writing. Printed Name Signature Date Rev. 06.2020 JMP 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx EMAIL CONSENT CLIENT INFORMATION CLIENT NAMEClient Information Client Name: DATE OF BIRTHDate of Birth: EMAIL ADDRESSEmail Address: Care and Counseling will use reasonable means to protect the confidentiality of and disclose Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) ). Care and Counseling will use reasonable means to protect the confidentiality of PHI sent and received through email. However, because of the risks outlined below, Care and Counseling cannot guarantee the security and confidentiality of email communications communications, and will not be liable for improper disclosure of confidential information that is not caused by Care and Counseling’s intentional misconduct. The risks of email communication include, but are not limited to:  • Email can be copied, circulated, forwarded, and stored in electronic files;  • Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients;  • Email is easier to falsify than handwritten or signed documents;  • Backup copies of email may exist even after the provider or client has deleted his or her own copy;  • Employers and online services may have a right to archive and inspect emails transmitted through their systems;  • Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information;  • Email can be intercepted, altered, forwarded, or used without written authorization or detection;  • Email may not be answered in the time frame expected by the sender. After reviewing the risks of email communication, you may authorize (client initials next to selected method): Encrypted email communication, a secure method, or Unencrypted email communication, an unsecure method. None; I do not consent to email communication If you authorize a By authorizing the above method of email communication, you acknowledge and agree to the following:  • I understand that Care and Counseling will read and respond to email communication as promptly as possible; however, a specific turnaround time is not guaranteed. Thus, I will not use email for emergencies or other time-sensitive matters.  • I acknowledge that some or all information sent or received via email may concern my diagnosis and/or treatment. Email may be included in my medical record or forwarded internally to other Care and Counseling staff as necessary for diagnosis, treatment, payment, and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my prior written consent, except as authorized or required by law.  • I understand that communication via unencrypted email is not secure and, therefore, Care and Counseling cannot guarantee the confidentiality of electronic PHI.  • I understand that Care and Counseling and its representatives are not liable for breaches of confidentiality caused by any third party or myself.  • I understand that I may, at any time, revoke my consent for email communications.  • Unless revoked in writing, this authorization will expire upon the later of the following events: 1) one (1) year after the date of my signature, or 2) the date on which I terminate care by Care and Counseling and its providers. I hereby acknowledge that I have read and fully understand the information provided in this Email Consent. Client Signature Date RIGHT TO REVOKE I request that my provider no longer use email Right to communicate with me. Client Signature Date Provider Signature Date J:\Clinical\Clinical Forms\Email Consent (Rev. 06.2020) 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx •xxx.xxxxxxxxxxxxxxxxx.xxx CLIENT GUIDE TO TELEHEALTH SERVICES “Telehealth Services” encompasses Video Therapy and Telephone Counseling. Telehealth involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with Care and Counseling, Inc. (“Provider”) and a client who are not in the same physical location. Telehealth Services may be used for diagnosis, treatment, follow-up and/or education. Please note that prior to beginning Telehealth Services, new clients will be screened by phone by their Provider to ensure suitability for this treatment modality. Care and Counseling is dedicated to ensuring you receive the best possible care with minimal interruptions. Many clients and Providers are moving to Telehealth services during a national crisis and to ensure health, safety, and continuity of care. For most clients, services will return to meeting in the same physical location (Care and Counseling office) when possible and agreed upon between the client and Provider. Please discuss the duration of Telehealth Services with your Provider. This guide is intended to help you successfully participate in Telehealth Services. It is not exhaustive and should not replace conversations with your Provider.Revoke