Bridge Point Evaluations LLC

Client Informed Consent

Electronic Communication Consent Form · Please read each section carefully and complete all fields before signing.

Formulario de Consentimiento Informado y Consentimiento de Comunicación Electrónica

Client Information

Client Name *

Date of Birth *

Preferred Name

Phone Number *

Email Address *

Date

2–3

Purpose of Consent, Informed Consent & Telehealth

I understand that Bridge Point Evaluations LLC provides mental-health services, which may include psychotherapy, psychological evaluation, assessment, consultation, and related professional services. My participation is voluntary and I may ask questions or discuss concerns at any time.

I understand that mental-health services may involve discussion of personal, emotional, psychological, medical, family, relationship, trauma, legal, or other sensitive information, and that there may be potential benefits and risks, including the possibility that discussing difficult experiences may temporarily increase emotional distress.

When services are provided through telehealth, I understand that electronic communication technology will be used and that risks include interruption of connection, technical difficulties, risks to confidentiality, and limitations associated with not being physically present with the clinician. Reasonable safeguards will be used to protect my privacy.

Entiendo que Bridge Point Evaluations LLC proporciona servicios de salud mental a través de teleterapia y que mi participación es voluntaria.

Consent to Phone Communication

I authorize Bridge Point Evaluations LLC and my treating/evaluating clinician to contact me by telephone at the number provided above.

YES, I consent to telephone communication.NO, I do not consent to telephone communication except when required for safety or other legally permitted purposes.

Voicemail preference:

I authorize voicemail messages.I do not authorize voicemail messages.Voicemail may be left, but only with limited information.

Special voicemail instructions (optional)

Consent to Text Message Communication

Text messaging may be used for appointment scheduling and reminders, confirmations, changes or cancellations, administrative communication, billing, and other limited communications. I understand that ordinary text messaging may not be completely secure and should not be used for emergencies.

YES, I consent to text-message communication.NO, I do not consent to text-message communication.

Consent to Email Communication

Email may be used for appointment scheduling, administrative communication, billing, sending or receiving documents, and other communications related to my services. I understand that email may involve privacy and security risks and agree to use reasonable precautions to protect my email account and devices.

YES, I consent to email communication.NO, I do not consent to email communication.

Electronic Communication Boundaries

Electronic communications are intended primarily for routine and administrative use.
My clinician may establish reasonable response times for calls, texts, and emails.
Electronic communication should not be relied upon for emergencies.
Clinically relevant electronic communications may become part of my clinical record.
Electronic communications may be stored in accordance with applicable legal and privacy requirements.

Emergencies & Crisis Services

If you are experiencing an emergency or believe that you or another person is in immediate danger: Call 911, go to the nearest emergency department, or contact an appropriate crisis/emergency service. Text messages, email, voicemail, and routine electronic communication are NOT emergency services.

Emergency Contact Name

Relationship

Emergency Contact Phone

Communication Preferences

Please select your preferred methods of routine communication (select all that apply):

Preferred method

Preferred days/times for communication

Other communication instructions (optional)

Consent for Electronic Records & Signature

I understand that this consent form may be provided, completed, signed, and stored electronically. My electronic signature has the same intended effect as my handwritten signature to the extent permitted by applicable law.

I have read and understand this consent form.I have had an opportunity to ask questions.I understand the potential privacy risks associated with electronic communication.I understand that I may withdraw my consent to text or email communication at any time.I understand that withdrawal of electronic communication consent does not automatically terminate my mental-health services.I understand that electronic communication is not intended for emergencies.I have received, or have been given an opportunity to review, the applicable Notice of Privacy Practices.

Client/Patient Printed Name *

Electronic Signature — type your full name *

Date

Time

Parent / Legal Guardian Consent

Client is a minor

Check "Client is a minor" above to complete the guardian section.

By submitting, you confirm that all information is accurate and that your typed name constitutes your electronic signature.

Al enviar, confirma que toda la información es correcta y que su nombre escrito constituye su firma electrónica.