• Recording Informed Consent

    Provided by: Wellness Grove
  • Client Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • If the client is under 18 years old you will be required to describe your relationship to the client at the end of the Recording Informed Consent form.


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  • Permission for Recording and/or Observation

    This form is used to obtain informed consent for recording and/or observation of therapy sessions for supervision and training purposes. Participation is voluntary. This form will be uploaded into the client’s chart at Wellness Grove upon completion.

  • I voluntarily give permission for the following (check all that apply)*

  • to occur beginning on Pick a Date and continuing until clinical services with a Wellness Grove Trainee are completed, field. Please add appropriate fields and text.

  • Purpose of Recording / Observation

    I understand that recordings and/or observations are used solely for professional training and supervision, with the goal of improving clinical competence and ensuring quality client care.

  • Recordings may be reviewed only by the following individuals (check all that apply)*

  • Confidentiality and Use

    • Except as required by law, court order, or applicable ethical obligations, recordings will only be accessed by the individuals identified in this authorization.
    • Reasonable efforts will be made to minimize the disclosure of identifying information. However, because the recording captures an actual therapy session, complete de-identification cannot be guaranteed.
    • Recordings will be handled and stored in a secure manner consistent with ethical and professional standards.
    • Recordings will not be used for any purpose other than supervision and training.

  • Right to Withdraw Consent

    • I may request that a recording be stopped or erased at any time, including before it has been reviewed, without penalty or retaliation.
    • I may revoke this consent at any time by notifying my clinician or Wellness Grove support staff. Revocation of this authorization will not affect any review or use of recordings that occurred before Wellness Grove received notice of the revocation.

  • Destruction of Recordings

    • Recordings will be permanently deleted or destroyed prior to the ending of the term or upon completion of supervisory review, whichever comes first.
    • Upon completion of the authorized educational purpose, recordings will be securely deleted from active storage systems maintained or controlled by Wellness Grove and the student, to the extent reasonably practicable.
    • Destruction will be verified by the student and/or university supervisor.
    • Students will document the destruction of the recorded material within the client’s chart.

  • Additional Clarification for Video Recording (if applicable)

    If video recording is used, reasonable steps will be taken to protect my identity (e.g., camera positioning), when possible and appropriate.

  • Acknowledge & Sign

  • By signing below, I acknowledge that:

    • The purpose, risks, and limits of recording/observation have been explained to me.
    • I understand that despite reasonable safeguards, no electronic storage or transmission of information is entirely free from risk, and I acknowledge this limited risk when consenting to recording.
    • I have had the opportunity to ask questions.
    • I give informed and voluntary consent.
    • This authorization shall be governed by applicable federal law, including HIPAA, and the laws of the State of Ohio (to include mandated reporting laws).
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: