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Authorization for Audiovisual Recording

1258 High Street, Eugene, OR 97401

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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)

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 the case is closed, any and all of the audiovisual recordings will be erased.

I understand that:

Audiovisual recordings are for educational purposes only and are deleted following the review.
Audiovisual recordings are available for viewing by client and/or any other parties designated by client. If I wish to view an audiovisual recording, I will make the request soon after session, and I understand the recording may have been deleted.
CFD does not release copies of recorded sessions.

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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I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

September 24, 2020 12:15 pm PDT

Authorization for Audiovisual Recording Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

September 24, 2020 3:56 pm PDT

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 PDT

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 PDT

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 PDT

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 PDT

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 PDT

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