Therapist Recording Consent Form
Please review and complete this form to provide your consent for session recording.
Client Full Name
*
First Name
Last Name
Client Email Address
*
example@example.com
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Therapist/Practice Name
*
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Recording Authorized
*
Audio Recording
Video Recording
Purpose of Recording
*
Clinical documentation
Supervision or consultation
Training and education
Other
If you have any specific conditions or limitations regarding recording, please specify below.
Client Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: