Photography, Video, And Teletherapy Consent And Authorization

Michele D. Shieldes, Pllc / Innovative Therapy Group

1. Authorization For Photography And Video Recording

I hereby authorize Michele D. Shieldes, PLLC / Innovative Therapy Group (“Practice”) to photograph and/or record video and/or audio of the above-named patient.

I understand that recordings for clinical purposes are part of the designated record set and will be maintained in accordance with applicable federal and Texas law. Recordings used for marketing will not include identifying information without separate written authorization. Once materials are used in external publications or media, they may not be fully retractable.

2. Teletherapy Informed Consent

I consent to the provision of therapy services via teletherapy (telehealth), which may include real-time audio, video, and/or electronic communications.

I acknowledge and agree that:

• Teletherapy will use secure, HIPAA-compliant technology to protect confidentiality.

• There are inherent risks, including interruptions, unauthorized access, or technical failures.

• I am responsible for providing a private, safe, and appropriate environment.

• I will ensure appropriate supervision during sessions as needed.

• Sessions will NOT be recorded without separate written consent.

• I may withdraw consent at any time in writing, which may impact service delivery.

3. Confidentiality And Hipaa

The Practice will use and disclose information in accordance with HIPAA and applicable Texas law. Reasonable safeguards will be implemented, but absolute security cannot be guaranteed.

4. Voluntary Consent And Right To Revoke

• Consent is voluntary.

• Consent for marketing may be revoked at any time in writing.

• Revocation does not apply to information already used.

• Clinical records cannot be removed once created.

5. Release Of Liability

To the extent permitted by law, I release and hold harmless Michele D. Shieldes, PLLC / Innovative Therapy Group from liability arising from authorized use, except in cases of gross negligence or willful misconduct.

6. Consent Selection