PICTURE, AUDIO, and AUDIO VISUAL RELEASE

Client Name *

First Name

Last Name

Picture, Audio and Audio Visual Options *

I hereby give Back To Basics Behavioral Health Services, Inc. permission to take photographs, audio and audio visuals of my child in any and all publications and other media including Back To Basics website, social media (i.e. Facebook, Instagram, Twitter, etc).

I hereby give Back To Basics Behavioral Health Services, Inc. permission to take photographs, audio and audio visuals of my child only within the office. I understand that these pictures will NOT be shown outside the office, but may be viewed by members of the community as they enter the building.

I do not give my permission for Back To Basics Behavioral Health Services, Inc. to take pictures or take photographs, audio, audio visuals or social media of my child.

Guardian Name *

First Name

Last Name

Date *

MM

DD

YYYY