California Center for Behavioral Health

925 Ygnacio Valley Road, Ste 205, Walnut Creek, CA 94596 · (925) 289-9022 · Fax (888) 965-0556

Consent to Text Message Communication

I authorize CCBH to communicate with me by text message at the mobile phone number I provide below.

Not for emergencies. In a medical emergency, call 911, or call or text 988 (Suicide and Crisis Lifeline). Do not use text messaging for emergencies.

Messages you may receive

Appointment reminders and confirmations, telehealth session links, prescription refill notifications, responses to care-related questions you send, and general administrative communication about your care. CCBH will not send marketing or promotional messages.

Risks you accept

Standard text messages are not encrypted. Messages may be visible to your mobile carrier, stored on your phone where others may see them, backed up to cloud services, or used as evidence in legal proceedings. Messages between you and CCBH may become part of your medical record.

Frequency

Message frequency varies based on your care needs — typically 1 to 3 messages per month, up to a maximum of approximately 10. Message and data rates from your mobile carrier may apply.

Opting out

You may withdraw your consent at any time by replying STOP to any text, calling the office at (925) 289-9022, or notifying CCBH in writing or in person. Withdrawing your consent will not affect your treatment or any other aspect of your care.

Your Information & Consent

Patient's Name (printed)

Mobile Phone Number

Date

I am at least 18 years old, or I am the parent / legal guardian of the patient named above.

I have read and understand the above, and I consent to receive text messages from CCBH at the mobile phone number above.

Patient / Guardian Signature (type full name)