Permission to Use Photographs and Videos

Permission to Use Photographs and Videos
Client Name:
Client Date of Birth:

MonthDayYear
Date
Education & Documentation Purposes:

Here at Moving Mountains Therapy Center, PLLC, it is beneficial to use the opportunity of technological advances for the purposes of treatment, education, and documentation. Photos, videos, and voice-recordings give therapists further information to reflect upon to guide future sessions and when appropriate may allow us to show our client’s family units what our clients are doing in therapy sessions. Please mark below to indicate your preferences for having videos, photographs, or voice-recordings done during therapy sessions.
Permission for Educational and Documentation Purposes:

I DO give permission for the above stated client to be photographed and/or video taped for educational and documentation purposes.I DO NOT give permission for the above stated client to be photographed and/or video taped for educational and documentation purposes.
Marketing Purposes

Here at Moving Mountains Therapy Center, PLLC, we would love the opportunity to share the wonderful work our clients, their family units, and our team members do together to achieve our clients therapy goals! Please mark below to indicate your preferences for having videos/photographs of the above stated client used for marketing purposes.
Permission for Marketing Purposes:

I DO give permission for the above stated client to be photographed and/or video taped for marketing purposes.I DO NOT give permission for the above stated client to be photographed and/or video taped for marketing purposes.
Signature of Client or Responsible Party:

Clear
Name of Signer:
Date

MonthDayYear
Date
Should be Empty: