Consent for Photographing and/or Videotaping

CONSENT FOR PHOTOGRAPHING AND/OF VIDEOTAPING
As business owners and local and national trainers we often find it useful to take and share photographs and/or video clips of evaluation and/or treatment sessions of the individuals we support. Photographs and video clips may be used in public trainings as well as personal marketing activities (e.g., website, brochure We can also use videos to help up establish a baseline of skills at the start of treatment, provide training opportunities for team members and or document progress. We would therefore appreciate your consent to photograph and/or videotape our interactions.

If you do not comfortable with videotaping and or photographing for these purposes, please feel free to not complete this form.
I authorize Britteny Asher Consulting and Associates to videotape and/or photograph me within evaluations and/or treatment sessions. Signature

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I understand the records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time.

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I authorize Britteny Asher Consulting to use video clips and or photographs for marketing purposes (website, brochure).

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Video clips and or photographs used for marketing purposes (website, brochure)

Can include identifying information (e.g., name and age)Can not include identifying information (e.g., name and age)
I understand the records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time.

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Name of Individual to be photographed/videotaped
Signature of Individual / Guardian

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Printed name of Individual / Guardian
Date

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Date
Description of Personal Representative's Authority if not the individual
Should be Empty:

CONSENT FOR PHOTOGRAPHING AND/OF VIDEOTAPING