Consent for Audio/Visual Release
As part of our on-boarding paperwork, this release serves as a protection for you and Music Plus in allowable recordings.
At no time will the full name of our clients be spoken on the recording. Identifying factors such as age, location, and medical history will remain confidential. We may disclose a main diagnosis and general age range (i.e. “child/adult”).
For examples of client recordings, please visit:
Email address *
I ________________________________ (Parent/Power of Attorney/Self/Guardian), *
Your answer
(Please choose one or more) *
for ___________________________(Individual Receiving Services), *
Your answer
to be recorded by the therapists at Music Plus - Therapy Services of Boulder LLC. I give permission for these recordings (or lack of) to be used in: *
as of this date. *
A copy of your responses will be emailed to the address you provided.
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