Video Consent Form

Video Consent Form

  • INFORMED CONSENT and AGREEMENT to VIDEOTAPE SESSIONS


    JOY A. DRYER, Ph.D.

    Licensed Psychologist/ Psychoanalyst
    PACT Certified Clinician
    NYState License #7740
    jdryerphd@gmail.com

    92 Remsen Street Ste. 1A, Blyn Heights NY 11201
    31 Collegeview Avenue. Poughkeepsie, NY 12603
    www.joydryerphd.com
    Cell: 917-816-8882


    I. INFORMATION FOR YOUR INFORMED CONSENT

    A. THE PROCESS of PACT Sessions. The Psycho-biologic Approach to Couples Therapy [PACT]

    is one of the main therapeutic processes I will use in my work with you. It focuses on how our emotions and thoughts interact with our bodies: thus non-verbal communication is as important as the spoken word. In this context, a picture really is “worth a thousand words”, as the saying goes. Hence the importance and use of videotaping our sessions to convey information, interactions, and emotional context that cannot be described verbally.

    B. PURPOSES of VIDEOTAPING.

    1. To facilitate your therapy work with me;
    2. For teaching, supervision, and training of graduate students and other professionals;
    3. For research in the efficacy of the PACT approach compared to other models of couples therapy.
    4. Should any publication result from any of these activities, the material will be suitably disguised to the extent practical, and may be copyrighted.

    C. CONFIDENTIALITY.

    1. LOCATION. I will not use your tape[s] in your city of origin, i.e. where you live or work.
    2. NO IDENTITY. You will not be identified by name or location. Only your initials, the date, & my office location will be recorded.
    3. STORAGE. The digital record will be stored on a password protected or encrypted computer hard drive. This in turn will be stored in a locked cabinet as soon as possible.
    4. DISPOSAL. Tapes will be erased or recorded over after they have served one or all purposes noted above.
    5. II. YOUR AGREEMENT Your signature below indicates that you give me, Joy A. Dryer, Ph.D,. permission to videotape our sessions. And, you have read and understood the following:

      1. You can request to view, and/or to turn off the video recorder at any time and may request that the tape or any portion thereof be erased. You may terminate in writing this permission to videotape at any time.
      2. I may use your tape, suitably disguised to the extent practical as described above, for purposes described above.
      3. Your consent is voluntary, and there is no financial compensation involved for the use of these recordings.
      4. Your questions pertaining to this consent have been answered to your satisfaction.
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