Consent to Electronic Communication

I authorize CCBH to communicate with me by one or both of the methods below. Each section can be opted into independently. Methods I do not authorize will not be used.

Not for emergencies. If this is an emergency, call 911, or call or text 988 (Suicide & Crisis Lifeline). Do not use text or email for emergencies or for any time-sensitive clinical matter.

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A. Text Message (SMS)

I authorize CCBH to send me text messages at the mobile phone number below.

Mobile Phone Number

Check the box above first. Your number is included with this form only if you agree to text messages.

Messages you may receive (SMS)

Appointment reminders and confirmations, telehealth session links, prescription refill notifications, billing notices and payment reminders, links to questionnaires and symptom rating scales, responses to care-related questions you send, and general administrative communication about your care. CCBH will not send marketing or promotional messages.

Automated replies (SMS)

Some replies to your text messages may be written by an automated assistant that uses artificial intelligence (AI). Those replies are labeled as AI-generated. To reach a person, call (925) 289-9022.

Risks you accept (SMS)

Standard text messages are not encrypted. Messages may be visible to your mobile carrier, stored on your phone where others may see them, backed up to cloud services, or used as evidence in legal proceedings. Messages between you and CCBH may become part of your medical record.

Frequency

How often we text depends on your care: usually 1 to 3 messages a month, and up to about 10 a month, plus replies to any texts you send us. Message and data rates from your mobile carrier may apply.

Opting out of SMS

You may withdraw your SMS consent at any time by replying STOP to any text, calling the office at (925) 289-9022, or notifying CCBH in writing or in person. Withdrawing your consent will not affect your treatment or any other aspect of your care.

B. Email

I authorize CCBH to send me email at the address below.

Email Address

Check the box above first. Your email address is included with this form only if you agree to email.

Messages you may receive (Email)

Appointment reminders and confirmations, telehealth session links, billing statements and payment notices, intake paperwork and forms, links to questionnaires and symptom rating scales, responses to care-related questions you send, and general administrative communication about your care. CCBH will not send marketing or promotional emails.

Risks you accept (Email)

Standard email is generally not encrypted. Messages may be intercepted in transit, read or forwarded by anyone with access to your email account, stored on third-party email servers, backed up to cloud services, or used as evidence in legal proceedings. Email exchanges between you and CCBH may become part of your medical record.

Response time

Email is monitored during business hours and is generally not suitable for urgent matters. Please allow up to two business days for a response. For anything that cannot wait, call the office at (925) 289-9022.

Your responsibilities (Email)

Maintain the privacy and security of your own email account. Notify CCBH promptly if your email address changes or if you believe your account has been compromised. Do not share your email credentials with others if you wish to keep CCBH communications private.

Opting out of Email

You may withdraw your email consent at any time by replying to any email from CCBH with the word UNSUBSCRIBE, calling the office at (925) 289-9022, or notifying CCBH in writing or in person. Withdrawing your consent will not affect your treatment or any other aspect of your care.

Acknowledgment & Signature

Patient's Name (printed)

Date of Birth

I am at least 18 years old, or I am the parent / legal guardian of the patient named above.

I have read and understand the above, and I consent to the methods I have authorized in Sections A and/or B.

Patient / Guardian Signature (type full name)

Date

Language assistance and accessible formats

Free language assistance services, and free auxiliary aids and services such as qualified interpreters and information in accessible formats, are available to you. Call (925) 289-9022 (TTY: 711) or ask our staff. See our notice of nondiscrimination.