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*
PHONE NUMBER*
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.
DATE*
MM slash DD slash YYYY

THRIVING KIDS PROJECT