Consent for Usage of Software/Text/SMS Services
* indicates a required field
Love and Wellness Counseling
Phone number: 385-261-2171
628 N Pugsley St, Salt Lake City, UT 84103
* Policy & Consent for Usage of Software/text/SMS Services
Your name:
Name of minor client:
Your relationship to minor client:
​
Love and Wellness Counseling is mental health agency that helps clients improve their mental health difficulties.
If you want to become a client of Love and Wellness Counseling or If you are the parent or legal guardian of a minor child (herein, "Minor Client"), which means your child is under 18 years old, you must give your written permission and consent for the Minor client to use the Simple Practice Software and Services AND our RingCentral text messaging SMS services. You understand and agree, by signing this form, that you or the Minor Client's use of the SimplePractice Software and Ring Central Services will be governed by the same terms of service that are applicable to your use of the Simple Practice Software and Services.
We collect your email address and phone number in our website and this information is protected by HIPPA and is not sold or shared to other companies. If any changes to data security occur you will be notified.
SMS OPT-IN OR PHONE NUMBERS FOR THE PURPOSE OF SMS ARE NOT BEING SHARED.
You agree that the practice listed above has your permission and consent to use the SimplePractice Software and Ring Central Services to schedule appointments, communicate with you and/or the Minor Client, document and administer the Minor Client's care and treatment, utilize telehealth services, and all other actions in any way related to being the Minor Client's provider. We will use Ring Central to be able to text you, call you or email you about our services. All our phone calls are recorded by Ring Central, and they are protected by HIPPA and are compliant to remain confidential unless they need to be used as a mandate by the legal court system. Your information will be used by Love and Wellness Counseling only. You will not receive any advertisements from companies different that Love and Wellness Counseling, and your information won't be shared with other companies.
By signing below, you also attest to and certify that you are an adult or the Parent/Legal Guardian of the Minor client and that you have current and unrevoked legal authority to grant permission and consent to the above-listed practice permitting the Minor Client to use the SimplePractice Software and Ring Central Services. If you have any questions or concerns about our privacy policy please email us to: admin@loveandwellnesscounseling.com.
YOU AGREE THAT IF YOU ARE THE PARENT OF A MINOR CLIENT AND WHEN YOU NO LONGER HAVE SUCH AUTHORITY, YOU WILL IMMEDIATELY NOTIFY THIS CHANGE TO US IN WRITING.
*
BY SIGNING BELOW YOU HEREBY AGREE THAT YOU, OR YOU AS PARENT/LEGAL GUARDIAN OF THE MINOR CLIENT LISTED ABOVE, HAVE READ, UNDERSTAND AND AGREE TO THE TERMS OF THIS CONSENT AND THAT PERMISSIONS YOU HAVE GRANTED IN THIS CONSENT ARE WITHOUT LIMITATION.
I consent to sharing information provided here. ___________
​