—Use the top of this page for your letterhead.]
Release and Permission to Record Sessions and to Use Case Materials
As a therapist, I naturally want to know more about how therapy helps people. To understand therapy better, I must
collect information about clients before, during, and after therapy. Therefore, I am asking you to help by allowing me to
record our sessions, and also perhaps by filling out some questionnaires about different parts of your life—relation-
ships, changes, concerns, attitudes, and other areas. Video and audio recordings are sometimes used as aids in the
therapy process, in the education of mental health professionals, and in research. I need to have your written permis-
sion to make and use these recordings and materials for these purposes.
I would also be grateful for your consent to use your case material in my other professional activities. Your mate-
rial may help in the development of the mental health field or in the training of health care workers. It is possible that I
could use your material in teaching, supervision, consultation with other therapists, publishing, or scientific research. For
these purposes, I might use any of the following:
Clinical or case notes I or other professionals have taken during or after our sessions.
Psychological test responses and scores, questionnaires, checklists, and similar data collection forms.
Electronic or other recordings (such as audio and/or video recordings, transcriptions, case notes, physiological
monitoring, or any other recording method) of any interview, examination, or treatment with me, my employ-
ees, or other professionals. These recordings may include clients, therapists, or others, and may be made in my