Your privacy is important.

All therapy clients should my utilize phone number or the Simple Practice messaging to exchange private health information.

For other clients the TCR (National Carrier Agency) requires I gather the below permission for all text usage.

We may use SMS text messaging for certain types of communication with you, including

billing, customer service, appointment reminders and other administrative requests.

Please initial each section for your consent.

______

You agree to receive SMS text messages from us, related to services that we are

providing to you.

______

You understand that you can text us STOP at any time to opt out of receiving SMS text

messages from us. You can text us HELP at any time to receive help.

_____

Your mobile information will not be shared with any third parties/affiliates for

marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any

time if you want your information to be removed, you can contact us via our email address or

regular mail.

You can contact us for any privacy related queries via our email address or regular mail.

Our email address:

Our address:

Client full name: _______________

Client mobile #: _______________

Client signature: _______________

Date: _______________

Mobile SMS Privacy Policy and Customer Consent Form