Video, Photo, and Audio Release for Carryover & Educational Sharing

Client Name:

Client Date of Birth:

Date

Purpose of Carryover & Educational Sharing

At Moving Mountains Therapy Center, PLLC, we use technology to support treatment, education, and carryover of skills into the home and community. Short videos, photos, and voice recordings may help therapists demonstrate strategies, explain home programming, and show families or other approved parties how to support the client’s therapy goals outside of sessions. For some speech therapy evaluations, it may be necessary to obtain a language or speech sample and an audio recording may be taken for accurate assessment and scoring.

Permission for Carryover & Educational Sharing

Shared ONLY with parent/guardian and other approved parties. *All videos shared for carryover and educational purposes will be under 2 minutes in length and sent securely through encrypted Virtru email.

Please select one:*

I DO NOT give permission for the above-named client to be photographed, video recorded, or audio recorded for carryover or educational sharing.I DO give permission for the above-named client to be photographed, video recorded, and/or audio recorded for carryover and educational purposes. These materials (under 2 minutes, sent via encrypted Virtru email) may be shared with the parent/guardian and the following approved parties:Other

Permission for In-Session Documentation

Used only by the evaluating or treating therapist for treatment planning; NOT shared.

Please select one:*

I DO NOT give permission for in-session photos, videos, or audio recordings to be taken of the above-named client for evaluation, treatment and/or documentation purposes. *Note: if the client is completing a speech therapy evaluation, a language or speech sample audio recording may be necessary for assessment and/or scoring purposes. If you do not give permission for recording, please plan to discuss with your therapist.I DO give permission for in-session photos, videos, or audio recordings to be taken of the above-named client for evaluation, treatment and/or documentation purposes only.

Marketing Purposes

May include photos or short videos used for website, social media, brochures, or clinic materials.

Please select one:*

I DO NOT give permission for the above-named client to be photographed or video-recorded for marketing purposes.I DO give permission for the above-named client to be photographed or video-recorded for marketing purposes.

Signature of Client or Responsible Party:

Name of Signer:

Date