Photo, video, and recording consent

Client name *Client / guardian name *

I authorize (optional)

Photo or video for the clinical recordAudio recording for the clinical recordI decline clinical recordings

I authorize (optional)

De-identified clips for internal trainingI decline training use

Public use (leave blank if you do not want this)

I authorize a photo or short film on the R.O.S.E. website or Stories pageI authorize use in a printed brochure or share kitFirst name may be usedUse first name only / no last nameI decline all marketing and public use

Limits (faces to avoid, no school name, no diagnosis, etc.)Signature *Date *

Client name *Client / guardian name *

I authorize (optional)

Photo or video for the clinical recordAudio recording for the clinical recordI decline clinical recordings

I authorize (optional)

De-identified clips for internal trainingI decline training use

Public use (leave blank if you do not want this)

Limits (faces to avoid, no school name, no diagnosis, etc.)Signature *Date *