Form Photo/Video Release Lakewood | ABA & Behavioral Therapy for Autism

Connect Plus Therapy often uses photos and videos to provide feedback to staff, families, and students on their performance. The media is used for internal educational purposes and would in no way be available to the public.
By signing below you acknowledge that Connect Plus Therapy uses video surveillance in clinic spaces for the security of our clients and staff and to ensure treatment integrity.
Please select the applicable option:*

I give permission for Connect Plus staff to record or take photos of my child for internal educational purposes only.

I do NOT give permission for Connect Plus staff to record or take photos of my child.
Client's Name*
First Last
Client's DOB*
MM slash DD slash YYYY
Parent/Guardian Name*
First Last
Todays Date*
MM slash DD slash YYYY
Parent/Guardian's Signature*