I, , give permission to Oregon Community Programs to video tape my child’s treatment sessions and use the tape for supervision and/or training purposes.

I understand that the tape of the sessions filmed will be used for supervision and/or training purposes: my child’s therapist, , will show this tape to their clinical supervisor, and/or a clinician with more extensive experience doing P-CIT who might be providing advanced supervision to my child’s therapist, with the purpose of getting feedback about ways to improve her use and teaching of P-CIT to parents and/or other clinicians.  The tape may also be shown in the training of mental health professionals, including also students and faculty, training of caregivers seeking P-CIT, presentations with para-professionals such as child care providers, school teachers, teacher assistants, and family advocates, to show the specific techniques used in Parent-Child Interaction Therapy.  I understand that only very general information about my child’s case will be disclosed, and the supervisors, and/or trainees will be asked to maintain confidentiality.  I understand that my name and my child’s name may be heard throughout the tape.

I understand that my child’s therapist is bound by a confidentiality agreement.  Any breach of that confidentiality may necessitate immediate action by Oregon Community Programs;

I understand that I may revoke this permission to tape at any time during treatment;

I understand that the original copy of this permission to tape will remain in the agency’s file;

I agree to the stipulations as they are stated in this agreement, or

I agree to the stipulations as they are stated in this agreement with the following exceptions and/or additions.

Client’s Name

Name of Client’s Parent/Guardian       

(Phone Number)

(Date)