Consent for Contact

Lookout Mountain CSB
Full Name of Individual Receiving Services: *

First Name Last Name
Birthdate: *

Month Day Year
Consent For Contact
Contact Preference
There may be times when we need to contact you regarding your services here at our
agency. As a precaution to protect your privacy, we would like to know the best method
for communicating with you.
(check all that apply) *

Telephone Text message Mailed letter Email
Please enter email address:
example@example.com
I understand that text messaging and email are not secure means of communication and may compromise my confidentiality. Text messaging rates may apply. I understand that it is the Agency's policy to utilize these methods of communication at a minimum such as appointment reminders.

I understand that land lines and cell phone communication may not be completely secure and confidential. There is a possibility that someone could overhear or intercept my conversations.
Contact Information
Primary Telephone Number: *
Type of phone: *

Cell Home Work
Add another telephone number?

Yes
Secondary Contact Information:
Type of phone:

Cell Home Work
Would you like to receive reminder calls or messages regarding your appointments? *

Yes No
If we are unable to speak to you, is it okay that we leave a message? *

Yes No
Comments / Additional Instructions:
CONSENT
By signing this document, I am giving permission to be contacted by the method(s) indicated above. I have the right to change the preferred method of contact and may do so by informing a clerical support staff worker at this agency. I am responsible for keeping the agency updated with current contact information.
Signature *

Clear
Consent Effective Date:

Month Day Year
Should be Empty:

Lookout Mountain CSB

Consent For Contact

Contact Preference

Contact Information

CONSENT