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.
I give permission for Piedmont Music Therapy, LLC to record treatment sessions in the following methods: (choose from below)
Client's First & Last Name
How may we use the sound/audio/video files?
For treatment or educational use only. This may include staff review, school/agency inservice, professional conference trainings.
For promotional use. This may include internet, brochure, social media.
Who is completing this form? If person other than client, list FULL NAME and RELATIONSHIP to client.
Please date this consent:
Please list the time of this consent:
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
Send me a copy of my responses.
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This form was created inside of Piedmont Music Therapy, LLC.