• I consent to allow Nancy Goodman, LCSW, to use unsecured email and mobile phone text messaging to transmit to me the following protected health information:
• Information related to the scheduling of meetings or other appointments
• Information related to billing and payment
• Information related to sharing resources

I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time.