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Authorization for Audiovisual Recording

1258 High Street, Eugene, OR 97401

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

Authorization for Audiovisual Recording

Name: Date of Birth:

I authorize the use of any audiovisual recording made of myself and/or additional participants, for the purposes of:

(Please initial each authorized activity)

Supervision between my therapy provider* and clinical supervisor

Recordings by Mental Health or Recovery Therapist will be:

Deleted when my therapy is completed

Intern therapist: Delete when my therapy is completed

Kept for training purposes beyond my therapy

Training of therapy providers

Recordings by Mental Health or Recovery Therapist will be:

Deleted when my therapy is completed

Intern therapist: Deleted when my therapy is completed

Kept for training purposes beyond my therapy

Other

* Therapy Provider = Graduate Level Intern or Master's Level Therapist

I understand that:

Therapy providers will be asked to leave the training if they recognize me on the audiovisual recording as someone they know outside of the agency.
When audiovisual recordings are made by interns, all recordings will be erased when therapy is completed.
I may view audiovisual recordings. I understand that at time of request, a recording may have already been deleted.
CFD does not release copies of audiovisual recordings.
Upon written notice I may have any or all audiovisual recordings erased, and/or restrict their use to one or more of the above stated purposes.
I may revoke this Authorization at any time by notifying CFD at 541-342-8437.

NOTE: To be valid this release must be signed by anyone participating in the audiovisual recording.

This document is being signed by: ClientPersonal Representative, see below

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:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

September 24, 2020 12:15 pm PST

Authorization for Audiovisual Recording Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.6

September 24, 2020 3:56 pm PST

CFD 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

September 25, 2020 8:51 am PST

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

March 18, 2021 2:52 pm PST

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:52:10 - 65.157.96.202

March 18, 2021 2:52 pm PST

CFD 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 PST

CFD 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

March 20, 2023 1:57 pm PST

CFD 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

November 6, 2023 2:28 pm PST

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.3

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CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.3

April 23, 2024 10:19 am PST

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 150.252.241.2

April 25, 2024 4:04 pm PST

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.6