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:
I ________________________________ (Parent/Power of Attorney/Self/Guardian),
(Please choose one or more)
give permission for both audio and visual recordings
give permission for audio recordings only
give permission for visual recordings only
do not give any permissions
for ___________________________(Individual Receiving Services),
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:
educational and training purposes within Music Plus
certification presentations with other certified therapy providers
print marketing, such as brochures and flyers
media marketing on Music Plus' website
none of these
as of this date.
A copy of your responses will be emailed to the address you provided.
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