MNCP Educational Recording Policy and Consent - eSignature


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Recording Policy Agreement and Informed Consent

Your therapist is requesting permission to record your counseling session(s) on audio or video file(s). The purpose of the recording is to help your therapist serve you better and to review and evaluate their counseling techniques. No recording will be done without your prior knowledge and consent. These recordings will only be used for the purpose of clinical supervision provided by a supervisor.  All viewers of the file(s), including the therapist, are in accordance with the ethical codes of their Minnesota Licensing Board. The file(s) will be treated with confidentiality by being stored on a password-protected device and will be destroyed no later than the end of the present academic semester.

AGREEMENT: 

I understand that the sessions provided to me, (First & Last Name)  may be recorded via audio/video in order to supervise and evaluate the therapist’s effectiveness.  The audio/video recordings are not part of my case file. I further understand that confidentiality and safety of all recorded sessions will be maintained. Only authorized supervisors will access the recorded sessions. I understand that my family and myself can receive services with Minnesota CarePartner even if we do not allow the audio/video recording of sessions. 

This agreement will remain in effect until termination of services with MN Care Partner, or we are notified in writing of your wish to rescind your permission. 

By signing below, you are permitting your therapist to record your session(s) and review the file(s) with the aforementioned individuals for supervision purposes.

 

I consent to the audio/video recording:

 

My signature below indicates my understanding of and consent for recording sessions:

Client:    DOB: Date:

Therapist:    Date:

Leave this empty:

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Signature Certificate
Document name: MNCP Educational Recording Policy and Consent - eSignature
lock iconUnique Document ID: 40334b6be53445fb39cd409cf0a3a1bef394c44c
Timestamp Audit
September 3, 2021 8:09 am CSTMNCP Educational Recording Policy and Consent - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12