This is a form to request your consent to audio and/or video record your child’s therapy session. The recording provides your child’s counselor’s supervisor the opportunity to observe sessions and offer additional input into the treatment plan and diagnosis.

Here are some things to keep in mind:

1. You consent for your child's counselor to record your child's therapy sessions. Your consent is voluntary. You may decline or withdraw your consent at any time without it affecting your child's treatment.

2. During the session, you or your child may request the recording stop at any time or be erased if you wish.

3. The purpose of the recording is for your child's counselor's supervision and professional development, which could improve their treatment.

4. The recording will be erased after the supervisor reviews it with your child's counselor.

5. The recording will be stored in a secure location until reviewed and erased.

Your signature below indicates that you voluntarily give your counselor permission to record the session.