Consent to Release Music Therapy Material

Consent to Release Music Therapy Material

Nordoff-Robbins Music Therapy Australia is a non-profit organisation providing music therapy to people in need, training music therapists and developing music therapy practice through research. To educate the professional and general community about the benefits of music therapy as well as for reasons of accountability and research purposes, it is often essential to present externally the audio-visual and written material obtained through our standard recording procedure. This form seeks the consent of the client named below to use such material under agreed conditions. It should be signed by the client him/herself or his or her legal guardian when consent is given.

Section A To be completed by Nordoff-Robbins Music Therapy Australia Limited (NRMTA)

Peter McDonald of NRMTA requests (Name and title of person requesting consent)

consent for the following, in regards to our client: _______________________________________________ (CLIENT NAME)

The release of music therapy material (Please circle):

X Video footageX Audio material X PhotographsX Written materialOther: ________________________________________________________________________________________________________

For use by the following: (please circle):

Nordoff-Robbins website Musicworks! MagazinePromotional DVDAssignment for the MCMT course Journal publicationPresentation - course lecturePresentation - conferencePresentation - networking/ fundraising eventYouTubeNotes 4 Notes programOther: _______________________________________________________________________________________Specific details of selection/s: _________________________________________________________________________________

Consent is required by the following date: 4 May 2012

Section BTo be completed by the client him/ herself; or an authorised representative or legal guardian of the client.

I ____________________________________________of _______________________________________________________________(Full Name)(Address)

Hereby agree to the release and use of music therapy material of me or the above-named client in your care as described in Section A above (please circle chosen response):

1. The true name of : ___________________________________________________ (CLIENT NAME)Please circle:

May be revealed in the written text

May not be revealed in the written text

2. Video footage (with sound), showing : ___________________________________(CLIENT NAME)Please circle:

May show the whole person

May show the silhouette of the person and the face, but the face must not be recognizable (e.g. shaded)

May show the silhouette of the person but not the face

May not show the person at all

3. Still images showing: ______________________________________________________________(CLIENT NAME)Please circle:

May show the whole person

May show the silhouette of the person and the face, but the face must not be recognizable (e.g.shaded)

May show the silhouette of the person but not the face

May not show the person at all

4. Audio recordings of : _______________________________________________________________(CLIENT NAME)Please circle:

May be used with no restrictions

May be used but the persons name must not be heard

May not be used at all

Relationship to the client:

The client

An appointed guardian

A professional carer of the client

The clients spouse or de facto with a close, continuing relationshipA relative or friend of the client who has a close personal relationship with the client.

(Please circle your responses)I wish to sight the materials before they are released Yes / No

I wish to be provided with a copy of the materials to be releasedYes / No

Signature ______________________________________Date ___________________________

Please return this form to us by:

Fax to 02 4736 0211 orPost Locked Bag 1797, Penrith NSW 2751

For queries regarding this consent, please do not hesitate to call Nordoff-Robbins Music Therapy Australia Ltd on 02 4736 0240

Thank you for your cooperation

Form: Consent to Release Music Therapy MaterialVersion 2: April 2012Developed by Annette DelvecchioApproved by Jill Ritherdon