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: 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
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Audiovisual Recording
Agree & Sign