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
    Training of therapy providers

Recordings by Mental Health or Recovery Therapist will be:
    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:

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:

Signature arrow sign here


Signature Certificate
Document name: Authorization for Audiovisual Recording
lock iconUnique Document ID: 87c65f32936e97dc16d7fa274cdf5e1425020b80
Timestamp Audit
September 24, 2020 12:15 pm PDTAuthorization for Audiovisual Recording Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.3
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
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 PDTCFD 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 PDTCFD 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 PDTCFD 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 PDTCFD 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
November 6, 2023 2:36 pm PDTCFD 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