CONSENT form EXAMPLE only

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CONSENT form EXAMPLE only Powered By Docstoc
					Consent for The Use of Art Work (see note at foot of form*)


Placement setting                .......................                            (Location)

Art Therapy Service with . . . . . . . . . . . . . . . . . . . . .                  (person)


I hereby authorise the Art Therapist Student to show my art work, made in the
context of the art therapeutic relationship, to groups of professional clinicians or to
use photographs of my art work in a written context for educational purposes, in
order to illustrate the practice of Art Therapy.

I understand that the Art Therapist Student will show my art work within supervisory
contexts in order to offer me the best service and in Queen Margaret University in
confidential supervision groups but that my name and that of the Placement setting
will not appear in any these contexts and that confidentiality will be maintained at all
times.


Name : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date : . . . . . . . . .




Art Therapy Student Name : . . . . . . . . . . . . . . . . . . . . . .

Signature : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .




* Placement Locations should feel free to amend this form to suit their particular
circumstances.