Department of Psychology and Counseling
University of Central Arkansas
Informed Consent to Audiotape or Videotape Counseling Interviews
_________________________________ (name of the practicum agency or
setting) provides a variety of services to individuals and their families. It also supports
the teaching and training mission of the counseling programs at the University of Central
Arkansas. Because the agency provides a teaching-training function, permission is
frequently requested of its clients to audiotape and/or videotape the interviews that are
conducted by the professionals-in-training. Audio taping and video recording the sessions
are a significant component of counselor training. However, no recording is ever done
unless the client has given permission to do so. Therefore, we use this consent form to
obtain your permission to audiotape and/or video. Feel free to ask your counselor any
questions about the purpose of taping and use of the tapes.
Your signature below indicates that you give _____________ (name of your
counselor-in-training) permission to be audiotaped / videotaped (circle one or both) and
that you understand the following:
1. I can request that the tape recorder or video recorder be turned off at any time
and may request that the tape or any portion thereof be erased. I may
terminate this permission to tape at any time.
2. The purpose of taping is for use in training and supervision. This will allow
the above referenced counselor-in-training to consult with his or her assigned
supervisor(s) in an individual or group supervision format, who may listen to
the tape alone or in the presence of other counselors-in-training involved in
direct supervision.
3. The contents of these taped sessions are confidential and the information will
not be shared outside the context of individual and group supervision.
4. The tapes will be stored in a secure location and will not be used for any other
purpose without my explicit written permission.
5. The tapes will be erased after they have served their purpose.
______________________________________________
Name of Client (Please print)
______________________________________________ _______________
Signature Date
