Consent & Media/Artifact Handling Note (Drama Therapy)

Consent & Media/Artifact Handling Note (Drama Therapy)

Date/Time: [Date and time]

Clinician: [Name, credentials, role]

Setting: [outpatient / inpatient / school / community]; Format: [individual / group]

Location: [Clinic, site, or telehealth platform]

Reason for Note: [intake consent / new group start / first recording / change in storage policy / client request regarding artifacts / other]

Note Status: [Complete / Incomplete] (Mark Incomplete if any required signatures are pending.)

Participants and Consent Authority

• Individuals present: [Client name or identifier]; [Guardian/representative name, relationship, and basis for authority if applicable]; [Interpreter: language and modality if used]; [Others present with role]
• Decision-making capacity: [Intact / Limited] — [Brief capacity assessment statement]
• If capacity limited: Assent process: [description]; Consent provided by: [name, relationship]; Authority basis: [court order / healthcare proxy / parent / other]
• Guardian/authority verification: [Verified / Not yet verified] — [What was reported and plan to confirm if pending]

Informed Consent for Drama Therapy

(Document that informed consent was discussed as an ongoing process.)

• Nature of Services: [Drama therapy modalities that may be used: role play, improvisation, storytelling, enactment, movement, props, masks, scripts]; Anticipated frequency: [frequency and duration]
• Goals: [1–3 high-level aims in client's terms]
• Risks and Discomforts: [Risks discussed: emotional activation during enactment, unexpected memories, interpersonal intensity in groups, physical considerations such as fatigue, personal space, sensory sensitivity]
• Benefits: [Potential benefits discussed such as skills, insight, emotional processing, social support] (Document without guarantees.)
• Alternatives: [Options discussed: non-drama approaches, individual-only option, declining specific exercises, referral]
• Confidentiality: [Baseline confidentiality explanation including mandatory reporting, safety exceptions, and how records are maintained]
• Client Rights: [Rights reviewed: ask questions, decline or stop specific exercises without penalty, withdraw from therapy]
• Embodied Work and Physical Contact: Movement/proximity preferences: [preferences noted]; Personal space accommodations: [accommodations]; Physical contact policy: [Touch not used in this practice / Touch may be used]. (If touch may be used, document types, exclusions, consent status [yes / no / conditional], and ongoing consent plan. If client declines embodied work, document modification plan.)
• Client understanding: [Client summarized key points / demonstrated understanding]; Questions raised: [questions and how addressed, or none]

Group Therapy Considerations

(Include only when group therapy is offered or anticipated. Omit for individual-only treatment.)

• Confidentiality limits: [Document that confidentiality among members is expected but cannot be guaranteed; members instructed to discuss only their own experience without identifying others]
• Confidentiality agreement: [signed today / previously signed / pending / declined] (If declined, note eligibility implications per program policy.)
• Group conduct rules reviewed: No participant recording during group; no photographing others' work without permission; no tagging or identifying members on social media

Media Capture

Media Captured Today: [Yes / No]

(If No: "No photo, video, or audio recorded.")

(If Yes or planned, complete the following:)

• Media type: [photo / video / audio / screen capture]
• Content description: [individual client / group / artifact only]; Identifying features present: [yes / no]
• Purpose: [treatment documentation / supervision / training / research / marketing / client request]
• Consent obtained from: [client / guardian / both]; Method: [written / verbal / electronic]
• Access: [Roles or teams authorized to access]
• Copy to client: [provided / available upon request / not provided]
• Storage: [System and location per organizational policy]
• Revocation: [How to revoke and what happens to existing media per policy]

(Do not document media capture based on unsigned authorization.)

Client-Created Artifacts

Artifacts Status: [No client-created artifacts retained by clinician or program / Artifacts exist as described below]

(If artifacts exist, complete the following. Keep descriptions brief; do not recreate artifact content.)

• Artifact type(s): [script / mask / drawing / prop / journal page / recording / other]; Identifying information present: [yes / no]
• Ownership and custody: [client retains / program retains / shared] (If program retains, include brief rationale.)
• Storage: [Physical or digital location and access controls per organizational policy]
• Use restrictions: [treatment only / not for teaching / other]
• Return/destruction plan: [When artifacts will be returned or destroyed and by what method]

Consent Outcome

• Questions addressed: [yes / no] — [Brief summary if yes]
• Understanding demonstrated: [yes / no]
• Outcome statement: [Consent decision, e.g., "Client consents to drama therapy as described" / "Client declines recording; no recording performed" / "Client consents to artifact storage under stated conditions" / "Consent deferred; no media captured; no artifacts retained"]

(If consent not obtained, ensure Media Capture reflects "No" and Artifacts reflects no retention.)

Signatures and Attachments

• Signature(s): [Client / Guardian / Both]; Method: [written / electronic]; Witness if required: [name/title]
• Attachments: [Informed consent form / Group confidentiality agreement / Media release / Institutional policy acknowledgment / None]

(If required signature is pending, mark note Incomplete. Consent is ongoing; this note may serve as an addendum when methods, media, or artifact handling decisions change.)