Forms – Media Recording Release

Video/Audio Recording Release

Video/Audio Recording Release 2020-05-19

Video/Audio Recording Release

The purpose of this form is to obtain consent for video and audio recording at Child & Family Agency of Southeastern CT, Inc. (CFA). Videotaping and supervisory observations of sessions have been proven across many therapeutic settings to be an effective method to provide specific and efficient training and case support improving the outcomes for the families served. As a result, many of our programs require videotaping to aid in service delivery. We have adopted this best practice across the majority of our programs.

Client Information:

Client name(Required)

First Name Last Name

Preferred Name (if any)

Client date of birth(Required)

All individuals being recorded must consent. Please check below:

Video/Audio Release(Required)

I give permission to CFA to video/audio record our meetings.

I do NOT give permission for CFA to video/audio record our meetings.

In-Office Live Sessions(Required)

I give permission for CFA staff and Evidence-based Model Consultants to observe my in- office live sessions.

I do NOT give permission for CFA staff and Evidence-based Model Consultants to observe my in-office live sessions.

By signing below:

I understand that these recordings will be used for professional purposes only and will not be used outside the Agency.

I further understand that these recordings will be destroyed within one year of the date of my signature unless I give permission in writing for them to be kept longer.
I understand that I can revoke permission to record or observe sessions at any time.

Please Indicate Relationship to the Client(Required)

Self

Parent

Legal Guardian

Other Authorized Legal Representative

Other Authorized Legal Representative (specify)

Date(Required)

Name(Required)

First Last

Signature(Required)