AUTHORIZATION TO AUDIO OR VIDEO RECORD

Initial *

I hereby give my permission to Revive Center for Wellness, and its clinicians, to make audio and/or video  recordings of our therapy session(s).

Initial *

I understand that any and all recordings will be used exclusively for the purpose of providing clinical supervision and training to the clinician, either at Revive or the clinician's accredited university program.

Initial *

I understand that I have the right to be informed prior to a treatment session being recorded and have the right to request that it not be recorded.

Initial *

I understand that any person involved in providing or receiving clinical supervision is bound to the same ethical principle of confidentiality as a professional providing counseling.

Initial *

I understand that all recordings of treatment sessions will be erased within one year of its recording, unless I provide written consent to an extension.

Client Full Name *

Parent/Guardian Name (If Minor)

Clinician Assigned to Client *

Date *

Signature *

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