Client Recording Consent

By signing below, I full name* grant permission to Heart and Solutions, LLC to take and use videotape, and/or audio recordings of me and my sessions. I agree to my image, voice, video and/or name being used by my provider for the purpose of live supervision required by the Iowa Board of Behavioral Science. I understand that these recordings will be viewed by my provider and their licensure supervisor(s) for the purpose of professional clinical development and will not be shared with other employees or anyone outside of Heart and Solutions, LLC. Additionally, any and all video/audio recordings will be destroyed upon either 1) review by the therapist's supervisor and/or 2) completion of the therapist's licensure hours.

I release Heart and Solutions, LLC from any and all liability arising out of the use of my image, voice and/or likeness, including without limitation any claims arising out of my right of privacy or right of publicity. I am participating on a voluntary basis and no compensation will be paid for this use.

Please select all of the following that apply

I consent to video recordingsI consent to audio recordingsI consent to live observation in person or virtually

Client Name*

First NameLast Name

Client or Parent/Guardian Signature*

Date*

Date

*Jotform acts as a witness signature for this document