Pastoral Counseling Program at Neumann College

Clinical Record—Permission to Record—Observe Counseling Session

I (we) _______________________________________________________, hereby, authorize

_________________________________________ to make audio, audio-video recordings

and/or live observations of counseling sessions involving myself or members of my family.

I (we) understand that these procedures will be used for professional purposes only, i.e., for

consultation, educational, counselor-certification and/or supervisory purposes.

I (we) understand that a strict policy of professional confidentiality will be adhered to at all times.

I (we) understand that any recordings done will be erased/destroyed immediately following

supervision requirements.

Client Signature:  _____________________________________     Date:  __________________

Client Signature:  _____________________________________     Date:  __________________

Witness Signature:  ___________________________________     Date:  __________________