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
* Therapy Provider = Graduate Level Intern or Master's Level Therapist
I understand that:
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
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Audiovisual Recording
Agree & Sign