AGREEMENT TO PRIVACY & CONFIDENTIALITY OF AUDIOVISUAL PATIENT MATERIAL
Steven S. Shapiro, Ph.D.
The audiovisual demonstration portion of this training is possible due to the generosity of patients who gave permission to use audiovisual recordings of their sessions for teaching purposes so that therapists can improve their techniques. This is a wonderful and valued training aid. I appreciate the spirit of generosity and have an obligation to assure complete privacy to the patients who have allowed this valuable contribution to training.
In this spirit, you are asked to sign this agreement form and abide by the conditions listed as a requirement for acceptance into this course
I acknowledge that all audiovisual recordings shown in this course are the exclusive property of the instructor.
In consideration of my admittance into this course I hereby agree that I shall not electronically or in any other way (i.e.,transcription) copy, record or duplicate such material. I further agree, that to maintain confidentiality and privacy, I shall not refer to any patient seen in any manner or through any format outside of this course. This includes any description of the case, identifying material, characteristics, diagnosis, statements, history, etc.
For online courses/webinars such as this one, I agree that material will be viewed in an area that is completely private and will not be shared with, viewed by or made accessible in any way to anyone else. This includes the audio portion as well as the video portion.This agreement and all of the conditions stated apply equally to individual and small group supervision/consultation, whether conducted in person or through video conferencing.
I understand that I will be held fully responsible for any violations to these conditions as well as consequences resulting from these violations. Consequences for violating these conditions may range from dismissal from the course, notification to your licensing board or professional organization(s), up to and including possible legal action.
By submitting this document and registering for the course I am agreeing to all of the conditions outlined here and certify that I am a licensed mental health professional.
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