• Permission to Video or Audio Tape Therapy Session

  • The purpose of this document is to inform you clearly about the consultation session in which you will have the opportunity to participate. You will be interviewed by George Faller, certified EFT couple therapist and trainer, for a couple therapy session. In addition to providing a valuable therapeutic opportunity for you, the session is part of therapists’ ongoing professional development. A number of therapists who are training in Emotionally Focused Therapy will be viewing the session and they will participate in generating feedback for you. The goals of this session are two-fold: 1) to facilitate the process of your therapy; and 2) to add significantly to the professional competence of therapists.

    The session will last approximately 1hr to 1hr and 15min, after which the group will share some encouraging feedback for you. You will have opportunity to respond to, if you wish, about the feedback and the overall experience. There is no cost for this consultation.

    The therapist and any observing therapists are bound by professional ethics to keep the personal information you share confidential. As is true with any type of counseling and therapy services, information you share can only be given out with your written permission. Exceptions to this are any risk of imminent danger to yourself or to others, or if your file were to be subpoenaed or ordered into court for legal proceedings.

  • Agreement

  • I/we understand that the session is being simultaneously recorded and that at my/our request the recording can be erased after the session. I/we give George Faller, MS, LMFT, and the Couple & Family Institute of New England (CFINE) permission to record my consultation session for the following use:
  • I/we understand that my/our confidentiality will be protected at all times. If a therapist or researcher knows me/us in any way they will excuse themselves from viewing the session and will keep my/our confidentiality as per standard professional guidelines. I/we have read and understood the above and agree to participate in this consultation session.
  • Any electronic signatures appearing on this Agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.