Video Release Form

If you have any questions don’t hesitate to call us at 269-262-1815.

Name of Person Completing this Form
I/We, client(s)/Gurdian of client, of Midwest Wellness/NORA Mental, 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 Midwest Wellness/NORA 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 Midwest Wellness/NORA Mental Health. I/We also understand the recordings will be erased at any time and that the recordings are property of Midwest Wellness/NORA 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.
Client Name
MM slash DD slash YYYY