Speech Therapy Photo and Video Release Authorization Form

I, _________________________ (print name), hereby authorize [Practice Name] and its speech-language pathologists to:

Recording Authorization

• Capture photographs of myself/my child during therapy sessions
• Record video footage of speech therapy sessions
• Record audio during therapeutic interventions
• Document progress through visual/audio documentation

Permitted Uses

These recordings may be used for:

1. Clinical documentation and progress tracking
2. Treatment planning and assessment
3. Professional education and training
4. Insurance documentation when required

Terms and Conditions

• This authorization is valid for one year from the date of signing
• I understand I can revoke this authorization in writing at any time
• All media will be stored securely following HIPAA guidelines
• Media will not be used for marketing without separate authorization

Authorization

Patient Name: _______________________________

Date of Birth: ______________________________

Parent/Guardian Name (if applicable): _______________________________

Signature: _________________________________

Date: _____________________________________

Witness: __________________________________

Revocation

I understand that I may revoke this authorization at any time by providing written notice to [Practice Name].

This form complies with HIPAA regulations and professional speech-language pathology practice standards.