Audio and video recordings are used to aid the counseling process and to gain further understanding of important aspects of the treatment. Dr. Nioka Smith uses audio recording for note taking purposes which helps with the efficiency of client documentation. Audio and Video recordings may be used for ministry or counseling purposes only. If recordings are used, either your first or last name will be concealed. Refusal to sign this form will not affect your eligibility for receiving services at this agency; neither does your selection affect the quality of services received. You may revoke your consent at any given time via writing to Dr. Nioka Smith Counseling.

Consent to Audio record:

Please select an option

I give consent to audio record.

I do not give consent to audio record.

Consent to Video record:

Please select an option

I give consent to video record.

I do not give consent to video record.

Name

Client's Name

Date

My signature below indicates that I have read and understand the above information and have had the chance to discuss this with my counselor. I confirm that I am not under any duress. I have discussed this procedure with the counselor (Dr. Nioka Smith), including the Counseling policy on confidentiality.

Please type your name below, this will serve as your signature.

Name

First Name

Last Name