I authorize my clinician to record my therapeutic session(s). My therapist is: Jonobie Ford
I understand that recording sessions is a standard practice for the betterment of therapy and that the same standard of confidentiality will be provided for these recordings as with my health record.
I also understand that these session recordings will be made for the purpose of therapist self-review, case supervision, or peer consultation.
I understand that these authorized recordings will be destroyed as soon as they have been used for their intended purpose. They will not be maintained, nor will they become part of my treatment record.
I understand that I have the right to refuse to sign this form for authorization to record and that my refusal to sign this authorization will not adversely affect my ability to receive health care services.
I understand that I may revoke this authorization in writing at any time. If I revoke this authorization, the recording described may no longer be used as described in this authorization unless action has already been taken in reliance on this authorization.
I understand that I may terminate the recording of a session at any point in the session, for any reason. By signing this document, I attest that I am giving my consent freely and have not been coerced into giving permission and that I understand the above terms and agree to the recording of my/our sessions.