Example Permission to Record EMDR Client Sessions for Consultation Purposes

This sample permission form provides an example of informed consent language for recording EMDR client sessions for consultation and professional development purposes, with an emphasis on confidentiality and client choice.

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Example Permission to Record EMDR Client Sessions for Consultation Purposes

Last updated: 02/18/2026

This sample permission form is provided as an example only. It is intended to be modified to suit your specific consultation practice and needs.

I, [Client Name Here], give permission for the recording and discussion of my EMDR therapy sessions, and for presentation of my clinical progress, by [Therapist Name Here].

__ I understand that the purpose of the recording is for my therapist’s professional development in EMDR therapy.
__ I understand that confidentiality is of utmost importance and that my name will not be used in the presentation and that no identifying information will be shared.
__ I understand this presentation (i.e. recording) of my session(s) will be reviewed by my therapist, the consultant my therapist is working with, and potentially other clinicians who are participating in group consultation.
__ I understand that any recording will remain in the control of my therapist at all times, and will not be reproduced, unless by separate consent.
__ I understand this release will be retained in my file, unless I rescind it.
__ I understand that I can rescind this consent whenever I choose and that any recording of my session will be discarded at my discretion and direction, after discussion with my therapist.
__ I understand that if I am involved, or likely to be involved, in litigation that I may choose to decline this request for any recording or use of my clinical material, as caution against possible subpoena.
__ I understand that there is no obligation to consent, with no penalty or consequence for declining, and I consent freely.

I do not want my face filmed: [Client Initials Here].

Client Name (Print): ___
Client Signature: ___
Date: ___

Therapist Name (Print): ___
Therapist Signature: ___
Date: ___