Client Name: DOB : Client # :________________________

Options Location:

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.

By 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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Signature Certificate
lock iconUnique Document ID: 4acb8660dcf5882d5e47ced3d47cfc0ba22e514c
Timestamp Audit
May 12, 2020 8:00 am PDTVIDEO & AUDIO RECORDING CONSENT Uploaded by Adam Falk - IP
May 12, 2020 8:08 am PDTOptions Records - added by Adam Falk - as a CC'd Recipient Ip:
May 12, 2020 8:11 am PDTOptions Records - added by Adam Falk - as a CC'd Recipient Ip:
October 27, 2020 11:07 am PDTOptions Records - added by Adam Falk - as a CC'd Recipient Ip:
October 30, 2020 10:33 am PDTOptions Intake - added by Adam Falk - as a CC'd Recipient Ip: