Consent to Use of Digital Assistant: Central NM Intake forms are securely encrypted and HIPAA compliant. Consent to Use of Digital Assistant ID # CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB* MM slash DD slash YYYY EMAIL* Southwest Family Guidance Center (“SWFGC”) requests permission to use a digital assistant to help your provider prepare documentation related to the services you receive. The digital assistant creates a secure transcript of the session that is de-identified of personal information. The digital assistant does not store audio, and the de-identified transcript is deleted after the related documentation is completed . SELECT APPROPRIATE OPTION BELOW: I give permission for SWFGC to use a digital assistant during sessions involving myself, my child, and/or my family for the duration of our participation in services at SWFGC I decline to allow a digital assistant in sessions involving myself, my child, and/or my family. NAME*RELATION TO CLIENT*DATE* MM slash DD slash YYYY