VIDEO RECORDING CONSENT FORM FOR MINOR

VIDEO RECORDING CONSENT FORM FOR MINOR

UNIVERSITY OF THE SOUTHWEST COUNSELING

VIDEO RECORDING CONSENT FORM FOR MINOR

I understand that the practice counseling sessions provided to my child/teen, _____________________ (First & Last Name) by his/her counselor trainee, ________________________________ (First & Last Name) will be recorded in order to supervise and evaluate the counselor trainee. I further understand that confidentiality of all recordings will be maintained. Only the counselor trainee and his/her supervisor and/or faculty instructor will have access to the recordings. I understand that other counselor trainees may review the recordings for instructional/educational purposes only.

I may also contact the Mental Health Counseling Program Director, Dr. Carol Brennan (cbrennan@usw.edu), or Dr. Jeri Midgley (jmidgley@usw.edu ), Director of School Counseling at the School of Education at University of the Southwest.

My signature below indicates my understanding of and consents for recording sessions with my child/teen:

My child, or I can request that the recording device be turned off at any time and may request that the recording or any portion thereof be erased.

I may terminate this permission to tape at any time.

The purpose of recording is for use in training and supervision. This will allow the above referenced counselor-in-training to consult with his or her assigned supervisor(s) in an individual or group supervision format, who may watch the tape alone or in the presence of other counselors-in-training involved in direct supervision.

3. The contents of these recordings are confidential and the information will not be shared outside the context of individual and group supervision.

4. I understand that these recordings cannot be used in any other way than the aforementioned situations or for any other purpose without my explicit written permission.

5. All recordings will be erased after they have served their purpose.

6. My signature below indicates my consent for my child/teen to participate.

______________________________ _____________

Parent/Guardian’s Signature Date

______________________________ _____________

Client’s Assent/ Consent Date

Thank you!


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