I, , give my permission to Angie Heath, LCSW to employ videotape recordings of both of usvideotape recordings of only Angie to be used for audio transcripts of my psychotherapy sessions Starting on: Specifically, I give permission for the use of therapy recordings: for the purpose of Angie Heath to receive professional consultation to advance her work. The recording(s) may be shared in an individual or group setting with a remote consultant. (And those professionals are also required by professional ethics and the law to keep details/information of the consultation confidential.)in Angie Heath’s offerings of presentations to other therapists for the purpose of helping therapists grow in their application of therapy skills. Additional Permission for use: I understand that background information about me might be presented in conjunction with the recordings. I understand that I can rescind this release in writing at any time specifying the cancellation of original recording permission or usage of recordings. This can be mailed or given to this therapist. I understand that there is no obligation to consent, with no penalty or consequence for declining, and I consent freely. By signing this form today, I acknowledge my willingness to help advance clinical work. Signature: (Or Parent/Guardian signature if client is a minor) Contact Email: Date:
