Text Message (SMS) Communication Consent Form
Effective date: September 11, 2026
Manna Treatment ("Manna," "we," "us") would like your permission to send you text messages (SMS) to help manage your care. Please read this form carefully. Your consent is completely voluntary and is not required to receive treatment or services from Manna.
1. What you are agreeing to
By signing and dating this form below, or by checking the consent box and submitting this form (in person, by mail, or through our client portal/website), you are opting in to receive text messages from Manna Treatment at the mobile phone number you provide. This is the only way we will enroll you in text messaging — we do not enroll clients by default, and consent is never assumed or pre-checked on your behalf.
2. Types of messages you may receive
Appointment reminders and confirmations; scheduling changes such as rescheduled or canceled sessions, intake and orientation reminders; account balance and billing notifications such as balance due or payment reminders; and other administrative scheduling communications related to your care at Manna.
To protect your privacy, text messages will not include clinical details, diagnoses, treatment notes, or other protected health information beyond what is needed to identify the appointment or account (for example, a date, time, or dollar amount). See Section 6 for important privacy information about SMS.
3. Message frequency
Message frequency varies based on your treatment schedule and account activity. You should generally expect up to 4–6 messages per week while you are an active client of Manna Treatment (for example, around scheduled IOP days), and fewer messages between active episodes of care.
4. Message and data rates
Message and data rates may apply, as charged by your mobile carrier. Manna Treatment does not charge you for these text messages.
5. How to opt out or get help
To stop receiving text messages at any time, reply STOP to any message from Manna Treatment. You will receive one final confirmation text, and no further messages will be sent to that number.
For help, reply HELP to any message, or contact our front desk at 770.495.9775.
Opting out of text messages will not affect your treatment, services, or any other communications (phone, email, or mail) from Manna Treatment.
6. Privacy and security
Standard SMS text messaging is not a fully secure or encrypted method of communication. There is a risk that text messages could be intercepted, misdirected, or seen by someone with access to your phone. By consenting, you acknowledge this risk and agree that Manna Treatment may use SMS for the limited, non-clinical purposes described in Section 2.
You may withdraw this consent at any time using the opt-out instructions above, and you may request an alternative method of communication (phone or email) instead of text.
7. Carrier liability
Carriers are not liable for delayed or undelivered messages. Manna Treatment will not sell, rent, or share your mobile phone number or opt-in information with third parties for their own marketing purposes.
8. Your consent
Yes, I want to receive text messages from Manna Treatment about my appointments, account balance, and scheduling, at the mobile number listed below. I understand message frequency varies, message and data rates may apply, this consent is not a condition of receiving treatment, and I can opt out at any time by replying STOP.
Client (or guardian) information
Printed name
Mobile phone number
Signature
Date
This web page is for reference only. To complete and submit this consent form, please request a copy from our front desk or through your client portal.
Contact us
Manna Treatment
3305 Breckinridge Blvd #116, Duluth, GA 30096
770.495.9775
admin@mannatreatment.com