I/We, client(s)/Gurdian of client, of Leaders For Life Inc., hereby give consent to release the contents of any or all therapy video recordings via a secure (encrypted) internet web-conferencing application (i.e., Skype videoconference) for the purposes of education, training, and consultation activities. I/We understand there is a chance, however slim, of a confidentiality breach if electronic security measures are breached (virus or malware) and have been informed that my therapist is using standard of practice security protections (passwords and virus protection). I/We understand that health care information relevant to my therapy may also be released for the previous purposes, but that identifying information will be withheld or modified to maintain my confidentiality. I/We understand that the content of these recordings and relevant health care information will be released only to mental health professionals and trainees who are bound by law, professional college, or a confidentiality agreement to maintain client confidentiality. I/We also understand that this consent only permits other professionals to review the recordings and health care information with my Leaders For Life Inc. Mental Health Therapist and does not permit other parties to copy or retain possession of the previous information. Finally, I/We understand this consent is completely voluntary and that I/We are free to withdraw consent at any time while continuing to pursue the requested therapy services with Leaders For Life Inc. Mental Health. I/We also understand the recordings will be erased at any time and that the recordings are property of Leaders For Life Inc. Mental Health and may be erased at any time with no notice given to me and are not retained as part of the clinical record. I/We will be given a signed copy of this Consent Form.
