PDBTI Audio/Video Recording Consent Form

PDBTI values supervision as a tool to improve the quality of services and patient outcomes. The Audio Video Consent Form allows your therapist to record sessions in order to more effectively work with their supervisor. No-one outside of PDBTI will view or listen to these recordings unless you specifically authorize this, and all recordings are kept using strict security procedures in full compliance with HIPAA and relevant Oregon/Federal law.
If you are unsure how to fill out this form or if you need to sign one, we recommend you first speak with your PDBTI therapist or a support staff member.

Please review and fill in all appropriate fields on the secure form below. After you finish and “sign” to submit, you will have the option to immediately download a copy for your records. You will also be asked to enter an email address where you would like a confirmation email to be sent, which will include a link to access and re-download the completed form (up to 30 days). Make sure to only enter an email address if you are okay with the account users potentially accessing your completed PDBTI form!

If you do not have an email address, or if you prefer not to include one for privacy reasons, please enter the following placeholder email address: none@pdbti.org
If you use the placeholder email, a copy of the completed form will only be sent to PDBTI support staff for processing. You will still have the chance to download a copy of the form if you like on the submission confirmation page.

If you prefer to print and fill out an ROI form by hand instead, please visit our Client Forms page for printable versions.

If you run into any issues or need technical support, please contact our Portland front desk at (503) 231-7854 extension 0 or our Salem front desk at (503) 231-7854 extension 8, or your PDBTI therapist.