Recording Consent Form: Doña Ana FOR DOÑA ANA COUNTY ONLY. Submitted forms are securely encrypted and HIPAA compliant. Recording Consent Form: Doña Ana ID # CLIENT FIRST NAME*CLIENT LAST NAME*GUARDIAN FIRST NAMEGUARDIAN LAST NAMERELATION TO CLIENTEMAIL ADDRESS* THERAPIST NAME*By signing below I authorize Southwest Family Guidance Center to audio/video record sessions for the duration of our participation in therapeutic services. I understand that any recordings created will be used for clinician training and professional development purposes only, and in all such instances, confidentiality is carefully maintained. The therapist will inform you prior to recording a session. 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
