Electronic Signature Agreement
I give consent for myself and any minor child in my custody to Child and Family Agency of
Southeastern Connecticut to collect an electronic signature on documents including but not limited to
treatment such as assessments, treatment plans, and treatment plan updates. By signing below, I agree
that my electronic signature is the equivalent of my manual signature. I further agree that the use of a
keyboard and mouse to select an item and to collect the electronic signature constitutes my signature,
acceptance and agreement as if actually signed by myself in writing. I further agree that each use of
my e-signature in signing documentation constitutes my agreement to be bound by the terms and
conditions of the Electronic Signature Agreement as it exists on the date of my e-signature.
Revocation of Electronic Signature
I understand that I have the right to withdraw my consent to electronically sign documents.
Withdrawing consent can be completed by speaking with my Child and Family Agency staff in
person or by phone.