Email Authorization


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Email Authorization

Name:      Date of Birth:

There may be times during therapy when my therapist wants to provide me with written information, such as a copy of my Service Plan. If the best way to get information to me is by email, I understand I have a choice to have emails sent securely to protect the information or sent unsecure to make it easier for me to access the information.

Please select one of the options below:

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.


Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.


Leave this empty:

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Signature Certificate
Document name: Email Authorization
lock iconUnique Document ID: 88d131abd3a65f6e273b15a474804635fb429069
Timestamp Audit
August 28, 2020 11:03 am PDTEmail Authorization Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
August 31, 2020 12:19 pm PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
March 18, 2021 2:51 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:51:58 - 65.157.96.202
March 18, 2021 2:51 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 9:26 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202