Consent Form

I understand that music/art therapy sessions and music/art therapy events at Musical Between are occasionally recorded on audio and/or video and that these recordings may be used for the music/art therapy assessment and evaluation purposes as well as supervision purposes.

I also understand that music/art therapy students may be involved with music/art therapy sessions as part of their clinical placements.

Client's Name:

Name of the person who gives the consent (if different from the client):

Association to the client (if different from the client)

Media Consent

Do you give permission to Musical Between for the photograph(s) or video-recording(s) in Music/Art Therapy Sessions/Events to be used in official Musical Between publicity and promotional material, including website, Facebook page and newspapers?

Yes

If yes, please select one of the options below.

The client's name may be used in the material.

A pseudonym may be used as the client's name in the material.

NB: Please note that separate consent will be asked for other public activities such as film, research and public presentation purposes.

Signature

Date

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