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CiiAT - The Canadian International Institute of Art Therapy
The Proulx Global Education & Community Foundation
143 Joseph Street, Victoria BC, Canada, V8S 3H6
Phone: 1-866-452-4428
Email: [email protected] — [email protected]
Web: ciiat.org — proulxfoundation.org

Case Study Consent Form

I hereby acknowledge that I have received signed permission/consent from my client or, if they are a minor, their parent/guardian with , to share the following details with the Canadian International Institute of Art Therapy (CiiAT) and The Proulx Global Education & Community Foundation (PF):

To be shared

Photograph or otherwise reproduce images of the artwork they create during therapeutic and/or training sessions.

Use images of their artwork for the purposes of educational case studies, supervision sessions, and other learning opportunities while ensuring their identity remains anonymous.

Discuss elements of their clinical history and progress in relation to their artwork for educational purposes, with their personal identity protected at all times.

My client understands and agrees to the following:

client agrees to

The client retains the right to withdraw their consent for the use of their artwork or images at any time up to one (1) year after the final session they participate in.

The client acknowledges that any artwork or creative work already published at the time of withdrawal may not be recalled or removed from publication.

By signing below, I confirm that I have read and understood this release form and consent to the terms outlined above.

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Timestamp

Audit

2026-03-17 1:16 pm PDT

Case Study Consent Form Uploaded by Diane Irvine - [email protected] IP 24.207.102.9

2026-03-17 1:26 pm PDT

CiiAT Clinical Team - [email protected] added by Diane Irvine - [email protected] as a CC'd Recipient Ip: 24.207.102.9

2026-03-17 1:51 pm PDT

CiiAT Clinical Team - [email protected] added by Diane Irvine - [email protected] as a CC'd Recipient Ip: 24.207.102.9