ࡱ> wv{U bjbjnn A6aaB <<<<<PPP84<Pw&0%%%%%%%$(]+l&<&<<1&R<<%%V#@8$]A;v# %G&0w&#T++8$8$n+<$<&&w&+ B :  HYPERLINK "http://www.qub.ac.uk/?utm_source=logo&utm_medium=email&utm_campaign=QUB Email Signature"  The School of Psychology Doctorate in Clinical Psychology Consent to Write a Case Report Your therapist is a trainee Clinical Psychologist at Queens University Belfast. As part of their training they must submit examples of their clinical work for assessment to the university. I _______________________________________ confirm that I give my consent for ______________________________________ (trainee clinical psychologist) to write up a case report based on my contact with the trainee. I understand that: I can withhold my consent and this will not affect my treatment All identifying information about me will be changed in this written record The written work will be read by academic clinical psychologists at Queens University Belfast and possibly by an External Examiner from another University and will be used to evaluate the work of the trainee clinical psychologist that I am seeing for therapy. I have had the opportunity to discuss any concerns or queries regarding this. Signed: ______________________________________________________ Print Name: __________________________________________________ Date: _______/_______/_______ Name of Trainee Clinical Psychologist: ______________________________ Signature___________________________ Date:___________________ Queens University Belfast The School of Psychology Doctorate in Clinical Psychology Consent to the Use of Recorded Information For Training Purposes Your therapist is a trainee Clinical Psychologist Queens University Belfast and currently on placement in this service. As part of their training examples of their clinical work must be seen by their clinical supervisor based in this service. I _______________________________________ confirm that I give my consent for ______________________________________ (trainee clinical psychologist) to make an audio/video (delete as appropriate) recording of our therapy session. I understand that: The recording is entirely voluntary and my decision to give or refuse consent will not affect my entitlement to psychological therapy in any way. The recording will be listened to by the clinical psychologist supervisor of the trainee and will be used to evaluate the work of the trainee clinical psychologist that I am seeing for therapy. I can change my mind at any point during the recording and the recording equipment will be switched off and the recording destroyed. All material will be stored securely and that the recording will be destroyed after the relevant supervisor has listened to/watched it. I have had the opportunity to discuss any concerns or queries regarding this. Signed: ______________________________________________________ Print Name: __________________________________________________ Date: _______/_______/_______ Name of Trainee Clinical Psychologist: ______________________________ Signature___________________________ Date:___________________ Queens University Belfast The School of Psychology Doctorate in Clinical Psychology Consent to Audio Taping and Transcription of a Therapy Session Your therapist is a trainee Clinical Psychologist at Queens University Belfast. As part of their training they must submit examples of their clinical work for assessment to the university. I _______________________________________ confirm that I give my consent for ______________________________________ (trainee clinical psychologist) to make an audio/video (delete as appropriate) recording of our therapy session. I understand that: this recording will be used to form a written record of the session, after which the recording will be destroyed all identifying information about me will be changed in this written record the recordings are entirely voluntary and my decision to give or refuse consent will not affect my entitlement to psychological therapy in any way the transcript will not form any part of my national health records the written record will be read by clinical psychologists at Queens University Belfast and possibly by an External Examiner from another University and will be used to evaluate the work of the trainee clinical psychologist that I am seeing for therapy. I can change my mind at any point during the recording and the recorder will be switched off and the recording destroyed. I have had the opportunity to discuss any concerns or queries regarding this. Signed: ______________________________________________________ Print Name: __________________________________________________ Date: _______/_______/_______ Name of Trainee Clinical Psychologist: ______________________________ Signature___________________________ Date:___________________     6b. 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