Informed Consent
for the Processing of Personal Data Using AI-Assisted Practice Management Software
A. Your Practitioner
Practitioner Name: [FULL NAME OF THERAPIST/PSYCHOLOGIST/COACH]
Practice Name: [PRACTICE OR CLINIC NAME, if applicable]
License / Certification: [LICENSE TYPE AND NUMBER, e.g., "Licensed Clinical Psychologist,
License #12345"]
Contact: [PHONE / EMAIL]
B. Purpose of This Form
Your practitioner uses a professional software platform called AITACS CRM (AI Therapy
Assistant Calendar Suite) to manage their practice. This software includes an AI (Artificial Intelligence)
assistant that helps your practitioner analyze sessions and provide better care. This form explains how your
data is handled and asks for your consent.
C. What Data Is Collected
When you work with your practitioner, the following information may be entered into the software:
Contact information — your name, phone number, email address, and physical
address. This is used for scheduling and communication only.
Demographic information — your age, gender, marital status, education,
profession, and cultural background. This provides clinical context.
Clinical information — your presenting concerns, medical and psychiatric
history, previous therapy experience, session notes, treatment goals, progress notes, and assessment results.
Video session data (if applicable) — if your practitioner uses the
Platform's built-in video session feature, the session takes place via an encrypted WebRTC video connection.
If your practitioner activates the recording function, the audio of the session is recorded
and automatically transcribed into text. The raw audio file is permanently deleted from the Platform's servers
immediately after transcription is complete. The resulting text transcript and any AI-generated clinical notes
are retained for a maximum of 7 years in accordance with HIPAA record-keeping requirements
(45 CFR §164.530(j)), after which they are automatically and permanently purged. You have the right to request
earlier deletion at any time.
D. How the AI Assistant Works
The AI assistant is a tool that helps your practitioner by providing suggestions for therapeutic techniques,
identifying patterns across sessions, and summarizing progress. Here is what you should know:
Your identity is protected. The AI never receives your real name, phone
number, email, address, date of birth, or any other identifying information. Your practitioner assigns you a
pseudonym (a code name or nickname), and the AI only sees this pseudonym.
Clinical context is de-identified. Before any of your clinical information
reaches the AI, it passes through an automatic filter that removes any identifying details. The AI receives only
your pseudonym, your age (not your date of birth), and de-identified clinical notes.
The AI does not diagnose. The AI assistant is not a doctor, therapist, or
diagnostician. It does not make diagnoses, prescribe treatments, or make clinical decisions. All clinical
decisions are made solely by your practitioner using their professional judgment.
The AI does not store your data permanently. The AI provider (OpenAI)
processes your de-identified information and returns a response. API data is retained by OpenAI for up to 30
days for safety monitoring, then deleted. It is not used to train AI models.
Audio transcription (video sessions only). When a video session is
recorded, the audio file is sent to OpenAI's Whisper speech-to-text service for transcription. Before
transmission, the audio does not pass through the de-identification filter (de-identification applies to
the resulting text transcript). The audio file itself is permanently deleted from the Platform's servers
immediately upon completion of transcription. OpenAI processes audio under a zero-retention policy — the
audio is not retained by OpenAI after the transcription response is returned. The text transcript
is then de-identified and may be analyzed by the AI assistant as described above.
Encryption. All data sent to and from the AI is encrypted during
transmission (TLS 1.2+).
E. Your Rights
You have the following rights regarding your data:
1. Right to access — You may request a copy of
all data your practitioner holds about you in the software.
2. Right to correction — You may request
correction of any inaccurate information.
3. Right to deletion — You may request that
your data be deleted from the software, subject to legal and professional record-keeping obligations.
4. Right to opt out of AI processing — You may
request that your clinical data not be processed by the AI assistant. Your practitioner will then use the
software for record-keeping only, without AI analysis of your sessions. This will not affect the quality
of your care.
5. Right to withdraw consent — You may withdraw
this consent at any time by informing your practitioner in writing. Withdrawal does not affect the lawfulness of
processing performed before the withdrawal.
To exercise any of these rights, contact your practitioner using the information in Section A above.
F. How Your Data Is Protected
• Your data is stored in an encrypted database and in your
practitioner's secure browser.
• All 18 categories of identifiers defined by HIPAA are
automatically removed before any data reaches the AI.
• De-identification happens at two independent levels (in the
browser and on the server) for additional safety.
• Your practitioner follows strict security requirements for
their device and work environment.
• Your data is never sold, shared for advertising, or used for
any purpose other than your care.
• Video sessions are conducted over an
end-to-end encrypted WebRTC connection provided by Daily.co. Audio and video streams are transmitted in
real-time and are not stored by Daily.co. Raw audio recordings (if activated) are stored only temporarily on
the Platform's servers during transcription and are deleted immediately thereafter.
• Text transcripts of recorded sessions
are stored in an encrypted database and retained for a maximum of 7 years, after which they are automatically
and permanently deleted.
G. Important Limitations
• No digital system can guarantee 100% security. While extensive
safeguards are in place, a residual risk of unauthorized access exists with any electronic system.
• The AI assistant may occasionally produce inaccurate or
incomplete suggestions. Your practitioner evaluates all AI output using their clinical expertise before applying
it to your care.
• If you share identifying information verbally during a session
and your practitioner records it in the clinical notes, the automatic filter will attempt to remove recognizable
patterns (such as email addresses and phone numbers), but may not catch all forms of incidental identification
in free-text notes.
• Video infrastructure. The Platform uses
Daily.co, Inc. for WebRTC video conferencing. Daily.co is a US-based provider. While the Platform operates
under its own data protection agreements, a separate Business Associate Agreement (BAA) between the Platform
provider and Daily.co has not been executed. US-based therapists operating under HIPAA are responsible for
evaluating this limitation before using the video feature with protected health information. HIPAA-covered
entities are advised to consult the Business Associate Agreement for further detail.
• Recording is not automatic. The session
recording and transcription function is only activated by your practitioner manually. No recording takes place
unless your practitioner explicitly starts it. You will receive a notification on the client session page
before the session begins if recording is enabled.
H. Consent
By signing below, I confirm the following:
I have read and understood this Informed Consent form, or it has been explained to me in a language I
understand.
I understand that my practitioner uses AI-assisted software (AITACS CRM) in their practice, and I
understand how it works as described above.
I understand that my identifying information (name, contact details, date of birth) is
never sent to the AI — only a pseudonym and de-identified clinical context.
I understand that the AI does not diagnose conditions and does not
replace my practitioner's clinical judgment.
I understand that I may opt out of AI processing at any time without any impact on the quality of my
care.
I consent to the processing of my personal data, including health data (special category data), as
described in this form.
I understand that I may withdraw this consent at any time by notifying my practitioner in writing.
[VIDEO SESSIONS — check if applicable] I consent to participating in therapy sessions
conducted via the Platform's built-in video call feature (encrypted WebRTC connection). I understand that
the video infrastructure is provided by a US-based third party (Daily.co) and that my audio and video
streams are transmitted in real-time and are not stored by that provider.
[SESSION RECORDING — check if applicable] I consent to the audio recording and
automatic speech-to-text transcription of our video sessions by my practitioner using the Platform's
recording feature. I understand that: (a) the raw audio file is permanently deleted immediately after
transcription; (b) the resulting text transcript may be analyzed by the AI assistant as described in
Section D; (c) the transcript is retained for a maximum of 7 years; and (d) I may withdraw this consent
for recording at any time without affecting my right to continue therapy via video call.
Please sign and date below. If the
client is a minor, the parent or legal guardian must sign on their behalf.
Client Full Name (printed)
Parent / Legal Guardian Name (if client is a minor)
Parent / Legal Guardian Signature
Practitioner Name (printed)
License / Certification Number
This template is provided in English. If your clients require the consent form in another language, you are
responsible for providing an accurate translation. Ensure the translation preserves the meaning of all AI-related
disclosures and the client's rights as described above. The translated version should be reviewed by a qualified
professional before use.
Common languages for which translation may be needed: Hebrew (עברית), Russian (Русский), Arabic (العربية),
Spanish (Español), French (Français), German (Deutsch), Portuguese (Português), Chinese (中文).