PMT Audio/Visual Consent
The purpose of this form is to obtain your consent since a printer and signed copy is not available at your location.
Email address *
I give permission for Piedmont Music Therapy, LLC to record treatment sessions in the following methods: (choose from below) *
Required
Client's First & Last Name *
Your answer
How may we use the sound/audio/video files?
Who is completing this form? If person other than client, list FULL NAME and RELATIONSHIP to client. *
Required
Please date this consent: *
MM
/
DD
/
YYYY
Please list the time of this consent: *
Time
:
Thank you for providing consent for audio/visual recordings of services with client provided by the Board Certified Music Therapists on Staff at Piedmont Music Therapy, LLC. We are proud to work with individuals of all abilities in Greater Charlotte of the Carolinas. #safetyiskey
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