Informed Consent For Audio/Video Recording

Informed Consent For Audio/Video Recording

ARC Manor
Name of Client*

First NameLast Name
In order to ensure quality services, the use of audio/video recording may be utilized to enhance the supervision of counseling interns and practicum students. Recordings are considered part of the educational process and allow the practicum/internship student to learn more effectively.

Recordings are considered confidential and will only be used to assist in increasing counseling skills. The recordings belong to the agency and not to the intern/practicum student. The agency will destroy all recordings within 30 days of their initial recordings.
I,Client Name* , hereby give my consent for audio/video recording of my counseling sessions with ARC Manor staff/Clarion University Practicum/Intern Student. I understand that all appropriate safeguards have been taken to ensure confidentiality of the recorded counseling sessions and that I can revoke my consent at any time without compromising my treatment.
I accept a copy of this release:*

YesNo
Client Signature*

Clear
Date Signed by Client*
Witness Signature*

Clear
Witness Name*

First NameLast Name
Date Signed by Witness
Should be Empty: