Consent to Audio or Video Tape

(for Quality Improvement only)

Southwest Behavioral Health Center (SBHC)seeks to continually improve the quality of clinical practice. One of the most effective methods for doing that is for clinical supervisors and/or clinical peers to observe and review the clinical work of each provider. Audio or videotape is one of the most direct methods of observation of a provider’s clinical practice.

You can assist us in our effort to improve the quality of our work by allowing us to audio or videotape the treatment provided to you or your child. The only purpose of this audio or videotaping is the Quality Improvement of our work. These recordings will not be used for any other purpose. You will always know when a service is being recorded by audio or videotape and your provider will always ask your permission first before starting a recording machine.

These audio and videotape recordings are NOT part of your clinical record. These recordings CANNOT be released to or viewed by anyone outside of SBHC, except by your written approval. The recordings will be destroyed (erased) whenever one of the following takes place (whichever comes first):

  • You request in writing that the recording(s) be destroyed immediately
  • The recording(s) have served their purpose in the supervision or peer review process
  • 6 months from the date each recording is made (applies to each recording, individually)
  • Your treatment at SBHC is concluded and your case is closed. In rare instances, SBHC may request to extend the consent beyond the time of your treatment, but this will always be done in writing and requires a separate written consent from you.

CONSENT

I have read and understand the above statement regarding the purpose of audio and/or videotaping of clinical services: I understand that I can request, at any time, in writing, that the audio or video recordings of the services to me or my child be destroyed.Even if I do not request the destruction of the recording(s), I understand they will eventually be destroyed, as stated above. I also understand that the purpose of these recordings is Quality Improvement only and cannot be released to or viewed by anyone outside of SouthwestBehavioralHealthCenter, unless approved by me in writing. I also understand that I will be asked again, verbally, for permission to record, prior to each service, and will always know when services are being recorded. I understand I can always say ‘no’ to the request for recording even though I have signed this consent.

I therefore agree to allow services provided to me, or my child, to be audio or videotaped according to the stipulations made above.

Signatures:

______

ClientDate

______

Parent or Guardian(if client is a child or under guardianship)Date

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Witness Date

Consent to Audio or Video Tape – MG - 4-09