Permission to Video Record Permission for Video Recording Client Name* First Last Birth Date* MM slash DD slash YYYY Medicaid or Insurance #* Transformations providers are often required or motivated to video record their therapy sessions. Review of the recorded service with a clinical supervisor is a significant component of training and quality care and required by some state licensing boards. Your therapy session may only be recorded with your written permission. Recordings are considered protected healthcare information and are stored securely and shared only with your permission. Please read the following and indicate if you are willing to have your sessions recorded. 1. The purpose of video sessions is for use in training, supervision, and quality review. 2. Your provider will review the recordings on their own, with their supervisor or during case consultation meetings. 3. You may request that the recording be stopped at any point in times and may request that all or any portion of the recordings be deleted. 4. The content of the recordings are confidential and will not be shared outside of your provider’s individual and group supervision. 5. The recordings will be stored securely and will not be used for any other purpose without your written permission. 6. You have the right to review recordings with your provider during a counseling session. 7. Recordings will be destroyed when training or supervision is completed. Recordings will not be kept as part of a client’s record. Have you read the above information and do you give consent to have sessions video recorded?* Yes Signature of Client or Legal Guardian*Name of Person Signing* Email Address Date* MM slash DD slash YYYY Unique ID
