Consent To Use Information In Publication

I, hereby give my consent to the use by April Benson, Ph.D., of recorded information from my participation in a course she taught. She intends to use it for a new course she’ll offer to other therapists, who’ll pay a fee the course.

I am not being offered any compensation, nor am I under any compulsion or duress to give my consent to said publication.

I understand that if I so request, April Benson will remove any identifying personal information I gave on a digital recording, including my name, practice location, and the type of professional practice I have. She cannot, however, guarantee that I will not be recognized by others from the other recorded information to be published.

I understand that I have the option of placing limitations on what can be included about me and about my participation in the seminar. I give my permission as follows (please check one of the three options below):

 I give my consent without any restrictions. Remove identifying references about me. Other restrictions (specify):

I understand that I have the option of limiting or revoking this consent at any time before a final draft of the material is created for distribution. The date currently scheduled for final draft is February 1, 2012. I understand that April Benson must receive any limitation or revocation in writing before that date in order for it to be effective.

By checking the box below, and entering my name and today’s date, I am agreeing to the terms of this consent form.



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