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*Note regarding the use of electronic communication:(required)

Communicating via phone, text or email cannot be guaranteed to be confidential or secure. Information transmitted is not encrypted and data may be vulnerable to access by unauthorized third parties. Your counselor will only communicate with you in this manner for administrative or scheduling purposes. The practice does not have any responsibility or liability regarding any error, omission or loss related to electronic communication. This form of communication should not be used for emergency purposes.

By completing this form, I ackowledge that I understand the privacy and security limitations of electronic communication and agree to all terms thereof.