Consent to Record EMDR

Consent to Record EMDR & Case Discussion

CONFIDENTIAL

The purpose of this review is for the listed therapist's professional development in EMDR practice.

I understand that confidentiality is of utmost importance and that my name will not be used in the presentation nor will identifying information be shared.
I understand this presentation of my session(s) will be reviewed by the listed therapist, with the involvement of an Approved Consultant in EMDR, and potentially other Consultants in Training, and /or Certification Applicants.
I understand that any recording will remain in the control of the listed therapist at all times, and will not be reproduced, unless by separate consent.
I understand this release will be retained in my file, unless I rescind it.
I understand that I can rescind this consent whenever I choose and that any recording of my session(s) will be discarded at my discretion and direction, after discussion with the listed therapist.
I understand that if I am involved, or likely to be involved, in litigation, that I may choose to decline this request for any recording or use of my clinical material, as caution against possible subpoena.
I understand that there is no obligation to consent, with no penalty or consequence for declining, and I consent freely.

Client's therapist at The Peacemaker Center

Filming Option

Do not film the client's face.

Client Name*

First Name Middle Initial Last Name

Client's Age*

Client's Birth Date*

MonthDay Year

Client's Phone Number

Client Email*

example@example.com

Signatures

I/we acknowledge by our individual signatures below, that each of us has read this policy, that I/we understand it and have had an opportunity to discuss its content and that I/we give permission for the recording and/or discussion of the client's EMDR session(s), and for the presentation of the client's clinical progress by the listed therapist. Children under the age of 14 need signed consent from both parents or all legal guardians for treatment.

Client Signature if client is age 14 or older

Sign with your mouse, stylus, or finger Clear

1st Parent/Guardian Name if client under age 14

1st Parent/Guardian Signature if client is under age 14

Sign with your mouse, stylus, or finger Clear

2nd Parent/Guardian Name if client under age 14

2nd Parent/Guardian Signature if client is under age 14

Sign with your mouse, stylus, or finger Clear