Social Media

Please enter the Access Code provided to fill out the form.*

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Parent/Guardian Name*

First NameLast Name

Email*

example@example.com

Relationship to child*

At Therapy West, Inc., therapists videotape or photograph children who receive therapy services to help monitor and document a child’s areas of concern, as well as measure their progress. Videotapes and photos are used and reviewed by Therapy West, Inc. staff and occasionally may be used in research projects focusing on outcome measures.

Therapists are frequently asked to participate in research and teach at professional courses, seminars or workshops nationally and internationally, as well as to write articles or chapters in technical books. We often include videotapes, slides or photos during our presentations. If photos or videos are used for any of the above mentioned purposes, they will not have identifiable information. Parents are always welcome to view their child’s videotape at Therapy West, Inc.

I give consent for my child to be videotaped and/or photographed. I understand that my child's name and any identifying information will not be used in association with these images.*

YesNo

Therapy West, Inc maintains a brochure, website, Facebook page and Instagram page. Please mark your consent for staff and therapists at Therapy West, Inc to take photographs and videos of my child for the purpose of posting on these sites. With this consent, I hereby release and discharge Therapy West, Inc from any and all claims arising out of use of the photos and videos. This consent can be changed and revoked by parent at any time.

I provide consent for Therapy West, Inc to use photographs of my child on Therapy West, Inc.'s brochures:*

I provide consent for Therapy West, Inc to use photographs and videos of my child on Therapy West, Inc's website:*

I provide consent for Therapy West, Inc to use photographs and videos of my child on Therapy West, Inc's Facebook and Instagram pages. I understand that these posts may be accompanied with my child's first name. :*

Signature*

Today's Date:*

Date

Video, Photograph, and Social Media Consent