Authorization to Record

309 S. Sharon Amity Road, Suite 310
Charlotte, NC 28211

203 W. Main Street, Suite F3
Lexington, SC 29072

I authorize my Wellness Counseling Center therapist to make audio/visual recordings of my/our sessions. These recordings will be used for the sole purpose of my treatment and professional consultation and certification process for ICEEFT. They will not be released for any reason by any means including print or electronic media and the internet. I recognize I have the right to revoke this authorization at any time and must do so in writing.
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