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MK Counseling can contact me at this phone number:

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MK Counseling may contact me at this email address:

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If you selected yes, please check the appropriate boxes below:

I only wish to be contacted via secure communication means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means. Conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to MK Counseling communicating with me via unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment. N/A

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First Name

Last Name

Phone #

MK Counseling can contact me at this phone number:

Yes, and voicemails are okay Yes, but voicemails are NOT okay No

MK Counseling may contact me at this email address:

Yes No

If you selected yes, please check the appropriate boxes below:

I only wish to be contacted via secure communication means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means. Conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to Clarity Together communicating with me via unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.

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