Recording Consent Form FOR BERNALILLO, SANDOVAL AND VALENCIA COUNTIES ONLY. Submitted forms are securely encrypted and HIPAA compliant. Recording Consent Form: Bernalillo ID # CLIENT FIRST NAME*CLIENT LAST NAME*GUARDIAN FIRST NAMEIF CLIENT IS LESS THAN 14 YEARS OF AGE, A PARENT/GUARDIAN MUST SIGN. GUARDIAN LAST NAME RELATION TO CLIENT EMAIL ADDRESS* THERAPIST NAME*The client named above is currently receiving therapy services at Southwest Family Guidance Center (“SWFGC”). SWFGC requests permission to video/audio record certain sessions or parts of sessions for purposes of the therapist’s educational growth and skill development. Any recordings created will be used for clinical supervision and training purposes only, and confidentiality will be carefully maintained. Once the training and/or clinical supervision is completed, the recording will be deleted. If any questions or concerns arise regarding this recording, please contact the main office at (505) 830-1871 and ask to speak with the Clinical Director. Choose the applicable option below: I give permission to video record therapy sessions involving myself, my child, and/or my family for the duration of our participation in therapy services at SWFGC. I give permission to audio record therapy sessions involving myself, my child, and/or my family for the duration of our participation in therapy services at SWFGC. I decline to have therapy sessions involving myself, my child, and/or my family video/audio recorded. DATE* MM slash DD slash YYYY
