I do hereby authorize Jillian DePaul, Ph.D. to communicate with me for my own convenience, and without restriction or further qualification.

Limits: I understand that email is not a secure means of communication and that its use could result in the inadvertent breach of the confidentiality of my or my dependent’s medical and/or psychological information.

Liability: I hereby indemnify and hold harmless, absolve and release Jillian DePaul, Ph.D. from any and all responsibility for any breach of confidentiality or privacy that may occur, directly, indirectly or inadvertently through the use of e-mail, and I hereby waive any and all claims for liability which I might otherwise have for direct or indirect harm or damages caused by Jillian DePaul, Ph.D.’s use of e-mail.

Term: This authorization will remain in effect, unless revoked, until the completion of my treatment or evaluation with Jillian DePaul, Ph.D.

Revocation: I understand that I have the right to revoke this authorization at any time. Should I decide to do so, I agree to provide the notice of revocation in writing. The effective date of any revocation will be that date upon which the revocation is received, processed and all affected parties notified.

Guidelines & Limitations:

1. E-mail should not be used for discussion of sensitive or private information.
2. E-mail cannot be used for urgent/emergency matters; nor can it substitute for meeting in person.
3. E-mail can be delayed, lost or intercepted, and Jillian DePaul, Ph.D. does not use encrypted e-mail. Time-sensitive communication must be handled by telephone as the time frame within which my e-mails will be read by the intended recipient(s) is unpredictable.
4. Frequent or protracted e-mail communication is billable at our hourly rate and may not be billed to insurance.