SAMPLE FORM; PLEASE ADAPT FOR YOUR OWN PURPOSES AFTER SEEKING YOUR OWN LEGAL COUNSEL

Consent Form
for Audio or Video Recording of Psychotherapy

 

I (name) __________________________________________ authorize
(my therapist) __________________________________________

to audio or videotape my treatment interviews as an integral part of my consultation and therapy. I understand that the use of my audio or videotapes will be restricted to the following purposes:

Please initial to indicate your approval:

Initials
1. To be heard and/or viewed by myself and my therapist _______
2. Consultation with professional colleagues _______
3. Research evaluation of the processes of my treatment _______
4. Training of professional colleagues _______

I understand that my full name will not be revealed, and that the interviews, recordings and reports will be used solely for the purposes described above in accordance with the ethical standards of professional confidentiality for licensed mental health professionals.

I understand that I will not receive financial compensation for the use of these audio or videotape recordings. I further understand that should I wish it, at my written request, these tapes will be destroyed.

 

Signature ________________________________________ Date ___________________

www.affectphobia.org

1/30/03