Adult Video Release Form printable pdf download

The PROMPT Institute

1010 Marquez Place, Unit C

Santa Fe, NM 87505 USA

Phone: 505.466.7710 Fax: 505.466.7714

A non-profit organization for the study, education, research

and treatment of speech production disorders

ADULT VIDEO RELEASE FORM

The main goal of the PROMPT Institutes’ Mission is research and treatment of speech production

disorders. A secondary goal is to provide education about these disorders, their causes and

treatment approaches that are most effective, to speech-language pathologists, parents, caregivers

and the general public. As such, it is important that any information you feel could be helpful for

either research or education of other speech-language clinicians and or medical professionals, be

considered in your permissions. Thank you for your cooperation.

I GIVE____ DO NOT GIVE_____my consent for myself, my spouse or my adult child, or to be

videotaped by The PROMPT Institute, Inc. for the following purposes:

(Please check all that apply and initial where you agree to give consent.)

I understand that this videotape will be used only for the purpose of treatment planning and

evaluation and to provide feedback and PROMPT treatment suggestions to my clinician.

__________________

(Please initial)

I also give permission for The PROMPT Institute to copy and use portions of this videotape

for:

Teaching and/or data collection purposes. This information will be used to

further the understanding of speech disorders and their treatment. I understand

that neither my name nor family identity will be used.

__________________

(Please initial)

A single still photograph that may be placed on the PROMPT web page to

illustrate either treatment or satisfaction resulting from improved communication.

___________________

(Please initial)

Signed: _____________________________________

Date: _____________________

Client

Signed: ____________________________________

Date: _______________________

Prompt Institute Representative

Adult Video Release Form