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

Please consider:

1. You consent for your counselor to record your session. Your consent is voluntary. You may decline or withdraw your consent at any time without it affecting your treatment.

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

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

4. The recording will be erased after the supervisor reviews it with your 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.