Consent to Record Intern Counseling Sessions

Consent to Record Counseling Intern Session(s)

CONFIDENTIAL

As an element of the diverse services we offer, The Peacemaker Center offers internship positions to current graduate students from local colleges/universities, as an opportunity to grow and develop their skill and technique in counseling. Many college/university counseling education programs require that one or several counseling sessions within which the counseling intern participates be recorded for review and critique by that individual’s faculty or site supervisor. Counseling interns are required to be under direct supervision of qualified Clinical Supervisors who review some or all aspects of counseling services delivered. By signing this document, you understand and agree that:

You are not required and are under no obligation to record sessions with your counselor intern.
You may withdraw permission at any time during or after the recorded session. The quality of care you receive will not change or be affected by your refusal or withdraw of permission.
You have a right to review your recorded session with your counselor intern for a period of up to 180 days, or until the recording has been destroyed.
Your counselor intern receives supervision at The Peacemaker Center, as well as faculty supervision at the college/university listed below where the recording will be kept confidential.
You may be asked to sign a videotaping consent specific to the college/university the intern is attending.
The recording will be destroyed upon completion of review by supervisors.
The consent provided for recording sessions will expire 180 days from the date of your signature on this consent document.
A copy of this document will be retained in your records.
The recorded counseling session will only be used as a tool to help your counselor intern develop in his/her personal and professional growth.
You may contact The Peacemaker Center with any questions related to recorded sessions at 610-269-2661.

Counseling Intern at The Peacemaker Center

Intern's Supervisor at The Peacemaker Center

Intern's College / University

Filming Option

Do not film the client's face.

Client Name*

First NameMiddle InitialLast Name

Client's Age*

Client's Birth Date*

MonthDayYear

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 session(s), and for the presentation of the client's clinical progress by the listed counseling intern. 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

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

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