THE PROMPT INSTITUTE
A non-profit organization for the study, education, research and treatment
of speech production disorders
ADULT VIDEO RELEASE FORM
The main goal of the PROMPT Institutes’ Mission is research and treatment of speech production
disorders. A secondary goal is to provide education about these disorders, their causes and treatment
approaches that are most effective, to speech-language pathologists, parents, caregivers and the general
public. As such, it is important that any information you feel could be helpful for either research or education
of other speech-language clinicians and or medical professionals, be considered in your permissions. Thank
you for your cooperation.
I GIVE____ DO NOT GIVE_____my consent for myself, my spouse or my adult child, or to be
videotaped by The PROMPT Institute, Inc. for the following purposes:
(Please check all that apply and initial where you agree to give consent.)
I understand that this videotape will be used only for the purpose of treatment planning and
evaluation and to provide feedback and PROMPT treatment suggestions to my clinician.
__________________
(Please initial)
I also give permission for The PROMPT Institute to copy and use portions of this videotape
for:
Teaching and/or data collection purposes. This information will be used to
further the understanding of speech disorders and their treatment. I understand that
neither my name nor family identity will be used.
__________________
(Please initial)
A single still photograph that may be placed on the PROMPT web page to
illustrate either treatment or satisfaction resulting from improved communication.
___________________
(Please initial)
Signed: _____________________________________ Date: _____________________
Client
Signed: ____________________________________ Date: _______________________
Prompt Institute Representative
Rev: 5/09