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Phone: (413) 341-0543
For the Professional
For the Public
Couple Video Release Form
Permission to Video or Audio Tape Therapy Session
We consent to the video or audio taping of therapy sessions with Nancy Knudsen, LMFT. We are aware of the presence of the video and/or audio equipment and permit the use of all or part of the video and/or audiotape for the purpose of:
Check below the type of use you are permitting.
Our therapist's review of the video to assist in our therapy.
Our therapist's consultation with a clinical supervisor.
Our therapist's consultation with his/her supervision group.
In no way will the refusal to grant permission for this video or audio taping affect our receiving assistance for myself/ourselves. If at any time during the treatment process we wish to stop the taping, we may do so and still continue treatment.
Any electronic signatures appearing on this Agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.