Fillable Form

Video and Electronic Media Recording Release Form

Client/parent consent to record a session for supervision or training purposes.

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Recording Details

Client Name (or Client Initials)

Date of Session

Associate Name

Purpose of Recording

Clinical supervision review with the Associate's LPC Supervisor Training or educational purposes Other (describe below)

Other Purpose (if applicable)

Consent Statement

I understand that this session (or a portion of it) may be video and/or audio recorded for the purpose(s) checked above. I understand that the recording will be stored securely, accessed only by the Associate and Supervisor named above, and used solely for clinical supervision or training purposes. I understand that I may decline or withdraw consent to recording at any time without affecting the services I receive, and that declining will not impact my care.

I consent to being recorded as described above.

Signatures

Client / Parent or Guardian Signature

Date

Associate Signature (witness)

Date

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Filling this out digitally with a client? Use the link below to open a clean, signature-ready copy for printing during intake.

🖨 Printable Version for Client Signature (Intake)