Authorization for Audiovisual Recording


Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

Authorization for Audiovisual Recording

Name:     Date of Birth:

I authorize my clinician and Center for Family Development to use any audiovisual recording made of myself and/or my family, for the purposes of:

(Please initial each authorized activity)

    Clinical Supervision
    Presentation in supervision group(s)
    Research Purposes
    Other   

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 understand that when my case is closed, any and all audiovisual recordings will be erased.

I understand that any and all audiovisual recordings are available for viewing by myself and/or any other parties that I designate, while I am active in services.

NOTE:  To be valid this release must be signed by all family members 18 years old and over who will be involved in therapy.

This document is being signed by:

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:

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Signature Certificate
Document name: Authorization for Audiovisual Recording
lock iconUnique Document ID: 79f1fdf5bdd08bce51d44e3fd9e86ca7561d1687
Timestamp Audit
September 24, 2020 12:15 pm PDTAuthorization for Audiovisual Recording Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202
September 24, 2020 3:56 pm PDTCFD 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 PDTCFD 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