MARIA DROSTE COUNSELING CENTER
Consent to Audio/Video Record Therapy Session
For Use in Supervision
Date: ____________________
I, ____________________________________, give consent to my therapist,
______________________________________, at Maria Droste Counseling Center to audiotape or
videotape our therapy sessions.
I understand that these tapes are for used solely for training and supervision of my therapist and that they
are confidential, except that they may be shared with my therapist’s clinical supervisor.
I understand they will not be part of my record at Maria Droste and that all tapes will be destroyed by the
time that I end therapy or transfer to another therapist.
I understand that I can revoke this authorization at any time.
Signed:_______________________________
(Client's Signature)
Date:________________
Signed:_______________________________
(Therapist/Witness Signature)
Date:________________
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