Recording Consent Form: Santa Fe, Rio Arriba - Southwest Family Guidance Center & Institute

FOR SANTA FE AND RIO ARRIBA COUNTIES ONLY. Submitted forms are securely encrypted and HIPAA compliant.

Recording Consent Form: Santa Fe & Rio Arriba

ID #
CLIENT FIRST NAME*
CLIENT LAST NAME*
GUARDIAN FIRST NAME
GUARDIAN LAST NAME
RELATION TO CLIENT
EMAIL ADDRESS*
THERAPIST NAME*
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.
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.
DATE*
MM slash DD slash YYYY