Store – Notice of Privacy Practices – Release for Videotaping

As a primary tool in Gottman Method Couples Therapy, and in order to augment your therapy work, we use videotape feedback as part of therapy sessions. This means that we may ask to videotape you during specific dialogues or exercises, or during entire sessions. We will play back these tapes in sessions to help you see patterns of behavior between the two of you and to help you process conflicts. By viewing the videotapes in sessions, it allows us to “stop action” and process how you might approach a conflict in a more productive way. It also allows you to witness your progress as your relationship becomes more satisfying to both of you.

In addition to in-session use, we may wish to use the videotapes to receive consultation as part of supervision. Supervision is crucial to our ability to continue to hone our skills, and to enable you to receive the highest quality care.

During this process, your name will be kept confidential. In addition, all matters discussed in consultations will remain completely confidential with the consulting supervising clinician. The videotapes are not part of your clinical record and will be used for no other purpose without your written permission and they will be erased when they are no longer needed for these purposes.

These tapes are the property of CTI, and will remain solely in our possession during the course of your therapy. Should you wish to review these tapes for any reason, we will arrange a session to do so. These materials will remain in locked facilities at all times, or deleted after reviewing.

You always have the right to refuse to be videotaped, and can do so at the time when it is requested by your therapist. You will never be taped without your full awareness and consent.

CLIENT’S AGREEMENT
I understand and accept the conditions of this statement and give my permission to have my therapy sessions videotaped or digitally recorded. I understand I may revoke this permission in writing at any time, but until I do so it shall remain in full force and effect until the purposes stated above are completed.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.