CCTV CONSENT

(NB References to ‘therapy’ in this Form, includes all our therapy, therapeutic treatments, counselling, and other services.)

The purpose of making an audio-visual recording is to assist our work with you and help you get the most benefit from our therapy. Please tick as appropriate:

The recording may be used for therapeutic use.

• Supervision purposes / ongoing training
• Teaching and training of staff members
• Research
• Record of how a condition changes
• Inform you about treatments available
• For legal purposes

Before any recording or photography takes place, the therapist will explain to you the purpose of why this is being done and what the recording will be used for. You will then be asked to sign to confirm your consent.

We may review the recordings in our sessions with you.

CCTV CONSENT TO MAKE AUDIO VISUAL RECORDINGS OF MY THERAPY SESSIONS

I give permission for my therapist to make recordings of my therapy sessions for this course of therapy only.

I understand that, if I request, I will be given an electronic copy of these recordings for my personal use as part of my therapy.

I accept I am responsible for keeping my recording safe, destroying it when I have no further use for it and that Platinum Mind Therapy Ltd has no responsibility for it once it is given to me.

I understand my therapist may use copies of my recordings to improve the quality of my treatment by reviewing the recordings themselves and with other colleagues in the team who will also maintain confidentiality.

I understand if my therapist uses copies of my recordings to improve the quality of my treatment with colleagues outside of Platinum Mind Therapy Ltd’s team, my consent will be asked for beforehand.

I understand my therapist may show a copy of my recording to their supervisor/academic training institute for supervision purposes.

I understand I have the right to withdraw my permission to make recordings at any time before, during or after the sessions and that I can ask my therapist to stop the recording at any time. However, if I withhold or withdraw my consent, Platinum Mind Therapy Ltd shall be fully entitled to immediately stop providing any therapy to me.

I understand I have the right to see the video recording in the form in which it is intended to be shown.

I understand that the waiting areas and hallways of the clinic have active CCTV cameras, that actively record those areas for safety purposes, and I consent to my recording being taken in this regard.

I agree to the terms of Platinum Mind Therapy Ltd’s Privacy Notice, which is available at: www.platinummindtherapy.co.uk