Secure Contact Form

Agree to the use of conventional text, insecure email and phone calls. Conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to Shoreline Counseling, LLC's therapist’s and office staff communicating with me via unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.

Contact will be made only through secure email, portal messaging and phone calls. I only wish to be contacted via secure communication means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means.