JERSEY INNOVATIVE SERVICES
Shadowing Video/Audio Listening Consent
Your provider offers opportunities for other staff to observe them working as a NJ licensed clinician or Behavioral Assistant. Jersey Innovative Services is looking to provide the highest level of services to you and your family.
Consent for Audio/Video Listening I understand I am giving permission for this provider to be observed with my child by other Jersey Innovative Services staff. On this form, I am consenting to video/audio listening with this provider. You will be notified when the provider begins. You can also change your mind about participation and listening during a meeting and for any future meetings.
Your personal information and data will be kept private and confidential. Some limits to your Protected Health Information outside of the meeting, Federal law authorizes disclosure of information when there is: current harm to self, harm to another or harm from someone. It is our obligation to protect you and others around you.
Press submit once. Information sent confidentially.
Consent is valid on this day.
Contact the supervisor for positive comments or concerns: Info@JerseyInnovative.com
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JERSEY INNOVATIVE SERVICES 