How to Coach Yourself and Others Coaching Families | Page 232

Appendix II: Sample Video Consent Form

Consent Form for the Use of Video Tape
We give consent for the use of these video recordings for the following purposes:
1. To help the team deliver a more effective service to our family. For the purposes of supervision and in order
to plan future therapy sessions. Confidentiality will always be maintained. Viewing will be confined to the
regular members of your family therapy team.
2. For teaching & research, in order to develop our service through training other therapists, and improving
the service for families through research. Such tapes are only shown to audiences of professional clinicians
and researchers who are warned about the importance of confidentiality.
Please delete as appropriate.

Signed: …………………………………………………………………………
………………………………………………………………………………….
Dated: ………………………………………………………………………….
You

are

entitled

to

change

your

mind

about

the

consent

given

above

at

any

time.

All video material is stored in locked cabinets and every effort will be made to ensure confidentiality. No video
material will be identified using your family’s name.
Signed: …………………………………………………………………………
………………………………………………………………………………….
All Family Members
Dated: ………………………………………………………………………….
Member of Family Therapy Team

232