Electronic Request For Services

Please complete the electronic form below you will be contacted by email within 24 hours. By submitting this electronic form you attest that you have read and agree to the attached intake, consents, policies & procedures form- specifically the electronic communications policy.

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    I attest that I have read, understand and agree to comply with all of Laura McLaughlin's consents, policies and procedures herein. By submitting this electronic form I attest that I have read and understand the risks and benefits of electronic communications. Electronic Communications (EC) In a medical emergency, do not use email. Call 911. 1. Risk of Using Electronic Communications i.e. Email or Text The Provider will provide clients the opportunity to communicate by e-mail. Transmitting patient information by EC, however, has a number of risks that patients should consider before using EC. These include, but are not limited to, the following risks: • EC can be circulated, forwarded, and stored in numerous paper and electronic files. • EC can be immediately broadcast worldwide and be received by many intended and unintended recipients. • EC senders can easily misaddress an e-mail • EC is easier to falsify than handwritten or signed documents. • Backup copies of EC may exist even after the sender or the recipient has deleted his or her copy. • Employers and on-line services have a right to archive and inspect EC transmitted through their systems. • EC can be intercepted, altered, forwarded, or used without authorization or detection. • EC can be used to introduce viruses into computer systems. • EC can be used as evidence in court. • EC may not be encrypted. 2. Conditions for the Use Electronic Communications Reasonable means will be given to protect the security and confidentiality of EC information both sent and received. However, because of the risks outlined above, the Provider cannot guarantee the security and confidentiality of EC communication, and we will not be liable for improper disclosure of confidential information that is not caused by my intentional misconduct. Thus, you must consent to the use of EC for patient information. Consent to the use of EC: • EC may be forwarded to ES & EAP staff and agent necessary for scheduling. However, EC will not be forwarded to independent third parties without the patient’s prior written consent, except as authorized or required by law. • Although the Provider will endeavor to read and respond promptly to EC from a client, it is not guaranteed that any particular EC will be read and responded to within any particular period of time thus the patient shall not use EC for medical emergencies or other time sensitive matters. • If the client’s EC requires or invites a response, and the client has not received a response within a reasonable time period, it is the client’s responsibility to follow up to determine whether the intended recipient will respond. • The client should not use EC for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases AIDS/ HIV, mental health, developmental disability, or substance abuse. • The client is responsible for providing any type of information that the client does not want to be sent by EC in addition to sensitive material previously described. • The client is responsible for protecting his/her password or other means of access to EC. The Provider is not liable for breaches of confidentiality caused by the patient or any third party. • The Provider will not engage in EC communication that is unlawful, such as unlawfully practicing across state lines. • It is the client’s responsibility to follow up and / or schedule an appointment if warranted. • The client must be 18 years or older or an emancipated or self-sufficient minor before an EC can be sent about the client. 3. Instructions To communicate by or EC, the client shall: • Inform Provider of changes in his / her EC. • Put the client’s name in the body of the EC. • Include the category of the communication in the EC subject line, for routing purposes. • Review the EC to make sure it is clear and that all relevant information is provided before sending to me including a phone number. • Take precautions to preserve the confidentiality of your EC. • Withdraw consent to use EC only by written communication to Provider. 4. Alternative Forms of Communication I understand that I may also communicate with the Provider via telephone or during a scheduled appointment and that e-mail and text is not a substitute for the care that may be provided during an office visit. Appointments should be made to discuss any new issues as well as any sensitive medical information. 5. Types of EC (Email or Text Transmissions) that Client Agrees to Send and/ or Receive The types of information that can be communicated via EC include referrals, appointment scheduling requests, billing and client education. If you are not sure if the issue you wish to discuss should be included in an EC, you should call to schedule an appointment. 6. Security Measures used by the Provider As stated above, communicating via EC does come with privacy risk as stated above. The Provider cannot guarantee total confidentiality, reasonable safeguards to protect your health care information as required by law. The security measures taken include password protected screen savers, policies and procedures, and staff training requirements. 7. Termination of the EC Relationship The provider reserves the right and discretion to immediately terminate the EC relationship if the terms and conditions set forth above or otherwise are breached, determined to be unacceptable or no longer wishes to utilize the e-mail to communicate with clients. 8. Client Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form and the inherent risks of counseling and the associated risks of electronic communication and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that may impose to communicate with clients by EC.
  • Max. file size: 2 GB.

Please note: I do not accept insurance and professional fees in my private practice  are due upon service delivery.  

Laura McLaughlin LMFT, LMHC & Dream's Profile Photo

Moonlight Ranch
70 Scribner Road Tyngsboro, MA 01879
Phone: (978) 328-7346  
Hours of Operation: By Appointment only