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:
Training of therapy providers
Recordings by Mental Health or Recovery Therapist will be:
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:
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.
