Permission to Record Form

Date:

We,
Client names: and ,

give permission to our therapist, Simcha Shtull (MHCA.MC.60137436), to create a video recording of therapy sessions between Ms. Shtull and ourselves. The sole purposes of the recordings is for review in her advanced training classes and with her supervisor.

The recordings will be destroyed immediately following training and supervisory review, and no copies will be made under any circumstances. If anyone in the training class, or the supervisor, recognizes us in the video, s/he will not be permitted to view the video.

We understand that we may terminate the taping of a session at any point in the session, for any reason. We may also revoke this permission at any time. Barring that eventuality, this consent will expire one year from the date of signing.



Client Signatures:

Name:

Email:

Social Security #:

Date of Birth:

Telephone #:

Name:

Email:

Social Security #:

Date of Birth:

Telephone #:

By clicking the "Yes" box, we attest that we agree to the release of information to the above individual



Be Sociable, Share!