Consent and Release of Photographs / Videos

I give consent to Branched Out Therapy, Inc. or any party authorized by Branched Out Therapy, Inc. to photograph and/or video record in connection with his/her therapy sessions, for any purpose subject to the therapist’s discretion including but not limited to educational publication, for teaching purposes, and demonstration of progression of his/her skills.
I authorize Branched Out Therapy, Inc. to use pictures of for promotional purposes (ex. brochures, website, etc.)
I acknowledge that I will receive no financial compensation for providing consent since my participation with Branched Out Therapy, Inc. in providing my consent and release is voluntary.
I hereby release Branched Out Therapy, Inc., their contractors, their employees and/or any third parties involved in the creation or publication of Branched Out Therapy, Inc. Publication from any and all liability that may arise in connection with the expressed and implied use of all photographs and videos outlined in this form.
I reserve the right to revoke this agreement at any time. I understand that my right to revoke must be done in writing.
I am the client, parent or legal guardian of the person named below and have the legal authority to execute this consent and release.

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Signature of Client or Legal Representative *

Relationship to Client *

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