Consent for Use of Email - Non-therapy services
By signing this form, you are acknowledging and agreeing to comply with the following:
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Your desire to send and receive messages to/from your service provider using the
e-mail addresses listed below.
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You agree not to use the clinic email address when trying to contact the clinic or
your service provider in the event of an emergency, as the ASPIRE Clinic cannot
guarantee a rapid response via email.
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By signing, you are also aware that email is not a guaranteed or secure way of
sending and receiving information and that you may not hold the University of
Georgia, the ASPIRE Clinic or your service provider responsible for any breach
of confidentiality that results from the use of the email addresses listed below.
Please type or print clearly.
Client (1) email address:
___________________________________
Client (2) email address:
___________________________________
Client Signature:____________________________________ Date______________
Client Signature: ____________________________________Date______________
Service Provider Signature: _______________________________ Date______________
(Witness)
aspire@uga.edu