Consent Form

Educate. Motivate.

Consent to be Photographed, Audiotaped, and/or Videotaped

In order to provide excellent care, track progress, and assist in parent training, Tricia H. Rogers, MS-CCC may photograph, audio tape and/or video tape evaluation and treatment sessions to be used solely for instructional, educational and diagnosis purposes.

I am either signing for myself or have legal guardianship for the individual listed below and I agree to allow the named individual to be photographed, audiotaped, and/or videotaped as part of the evaluation and treatment sessions. I understand that Tricia H. Rogers, MS-CCC will not use the recordings outside of the clinic without further written consent by me.

Consent Form
Type your name here again to sign the form