VIDEO & AUDIO RECORDING CONSENT
Client Name: DOB : Client # :________________________
Options Location:Options Counseling and Family Services Location: Beaverton - 8285 SW Nimbus Ave, Ste 148; Beaverton, OR 97008 Fax: (503)352-3262Clackamas - 12901 SE 97th Ave, Ste 340; Clackamas, OR 97015 Fax: (503)655-6806Eugene - 1255 Pearl St, Ste 102; Eugene, OR 97401 Fax: (541)687-2063Florence - 1445 8th St; Florence, OR 97439 Fax: (541)997-8606Multnomah - 11010 SE Division St, Ste 202; Portland, OR 97266 Fax: (503)335-5974Newport - 119 NE 4th St; Newport, OR 97365 Fax: (541)264-7515North Salem - 2645 Portland Road NE, Ste 120; Salem, OR 97301 Fax: (503)393-3135Roseburg - 283 SE Fowler St, Ste 2; Roseburg, OR 97470 Fax: (541)464-6457South Salem - 1515 Liberty St SE; Salem, OR 97302 Fax: (503)468-3130Springfield - 175 West B St, Bldg D; Springfield, OR 97477 Fax: (541)762-1974St. Helens - 445 Port Ave, Ste C; St. Helens, OR 97051 Fax: (503)335-5974Woodburn - 1320 Meridian Dr; Woodburn, OR 97071 Fax: (503)498-5810
Services at Options may include the use of video and/or audio recordings of you and members of your family. These recordings allow staff to provide clinical consultation within the agency as well as outside the agency. These recordings are used for supervisory and training purposes only and to better serve our clients by providing the best treatment outcomes for the client.The internal/external consultation group may fluctuate and vary but can include supervisor(s): which may include academic supervisors, psychiatrist, and other Options’ employees. Any person(s) involved in this consultation are bound by the federal privacy laws and Options’policy and procedures protecting the confidentiality of all client information.ConsentBy initialing the consent box and signing this form, I authorize Options to make audio/video recordings of myself and members of my family for supervisory and training purposes. I understand that these electronic files will be encrypted and secured in compliance with federal privacy and security laws and will be erased or destroyed following supervisory review.I understand the services provided at Options are not contingent upon giving and signing this consent.I have read the above and fully understand the content. I have asked questions about anything that was not clear to me, and I am satisfied with the answers I have received. I understand I may withdraw my consent to make additional video and/or audio recordings without affecting the treatment process by submitting revocation in writing via certified mail. The consent automatically expires at discharge from services.
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Document Name: VIDEO & AUDIO RECORDING CONSENT
Agree & Sign