Consent to Record Sessions Conjoint Treatment

I,

First NameLast Name

And I,

First NameLast Name

consent to allow Ellen A. Scharffenberg to audio/videotape our conjoint therapy sessions. Ellen A. Scharffenberg has explained her commitment to improving the practice of couple’s therapy and how she plans to use the audio/videotapes.

We understand that the use and viewing of the audio/videotapes in whole or part is strictly limited to the following:

Analysis by Ellen A. Scharffenberg to optimize the quality of our care
Use by Ellen A. Scharffenberg for the purpose of professional consultation about our treatment
Use by Ellen A. Scharffenberg for the purpose of group supervision with other professional therapists

We understand that our names will never be disclosed, and that only therapists who do not know us will be allowed to view the tapes. We further understand that the tapes are not part of our permanent medical record and that Ellen A. Scharffenberg will destroy each tape/DVD after it has been used for its intended purpose. We understand that either of us may withdraw our consent at any time.

Client Signature

Date