I consent to allow Carolyn Dixon, LCSW, to videotape psychotherapy sessions. The purpose of this tape is to facilitate and better document the treatment, assessment process, and/or enhance supervision. I understand that the use and viewing of the audio/videotapes in whole or part is strictly limited to the following:

• review by Carolyn Dixon to optimize the quality of care
• use by Carolyn Dixon for the purpose of professional consultation about my treatment
• use by Carolyn Dixon for the purpose of group supervision with other professional therapists. I understand that my name will never be disclosed, and that only therapists who do not know me will be allowed to view the tapes.

I understand that:

• I am not required to be videotaped and I am under no obligation to have sessions recorded. I can withdraw my permission at any time during or after the session. My access to therapy services will not be affected by my decision not to be videotaped. 
• I have a right to review this recording with my therapist during a therapy session.
• I have the right to request that the camera not show my face and provide only audio recording. I can request that the tape recorder or video recorder be turned off at any time and may request that the tape or any portion thereof be erased. I may terminate this permission to tape at any time.
• The contents of these taped sessions are confidential and the information will not be shared outside the context of individual and group supervision.
• The tapes will be stored in a secure location and will not be used for any other purpose without my explicit written permission
• The tapes will be erased when they are no longer needed for these purposes.

I understand and accept the conditions of this statement and give my permission to have my therapy sessions videotaped or digitally recorded. I understand I may revoke this permission in writing at any time, but until I do so it shall remain in full force and effect until the purposes stated above are completed.