Video Release Agreement
For Confidential Review of Coach in a Client Session Recording
Today's Date (Click on Calendar to Choose Date)
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Month
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Day
Year
Date
Client Name
First Name
Last Name
Home Street Address
City
State/Province
Zip / Postal Code
Country
First and last name of my coach whom I am authorizing to record:
First Name
Last Name
Signature (use your Mouse or Finger to create signature)
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*Note* Please forward the PDF of this completed form that you receive via email after your hit submit to your coach so they can use it for their credentialing submission.
Submit
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