Patient/Client Media Consent Form

Patient/Client Media Consent

Aspire Behavioral Academy occasionally photographs, videotapes, or records clients during therapy sessions, agency events, or program activities. Because our clients are minors, this form must be completed by a parent or legal guardian. Declining or revoking this consent will never affect your child's services.

Client Information

Client Name *

Date of Birth

Purpose of Use

I understand that photographs, video, or audio recordings that include my child's image, voice, and/or likeness may be used for the following purposes (select some, all, or none):

Agency website Social media accounts (e.g. Facebook, Instagram, LinkedIn) Newsletters and print materials Internal clinical training materials (de-identified where possible) Accreditation, funding, or presentation materials (de-identified where possible)

Any use outside your child's individual treatment record will avoid identifying protected health information unless otherwise noted above.

Parent/Guardian Acknowledgment

I am the parent or legal guardian of the client named above. I understand this consent is completely voluntary, that I will not receive compensation, and that this consent remains in effect until I revoke it in writing.

Parent/Guardian Name *

Relationship to Client *

Electronic Signature (type your full name) *

Date *