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Sample Optional Testimonial Release Form

With your permission and participation, your therapist may ask you write a testimonial about the results of the work you did together. This is totally up to you; it can be very useful to other people suffering with a similar illness who are trying to decide if the treatment you received might also help them or not.

Note that your therapist may have his own form for this purpose. You can download the sample form by clicking here.

Revision 2.0; Nov 17, 2015

Intent: With your permission only, we may ask you for a written or video testimonial about the results of your treatment for use on our website. It would be a few paragraphs about your symptoms before treatment, and how your feel after treatment. Or we may ask you to do a video after treatment recorded specifically about the results of treatment. This is to either 1) help others who have a similar problem to feel that this might be appropriate for them also, or 2) to help others realize what we offer does not fit their situation. If you are not willing to do this, do not fill out this form. If you are willing to do this, please fill out the form below. If you are willing to do so, but want to keep your name private, just indicate this below in the appropriate box.


located at the address,

do agree to release any rights to the testimonial material video, sound recording, or written material. If I do not want my name used, but am still willing to have the video or written testimonial used on our website, I indicate this here:

I am willing to have my testimonial used with my real name; or

I am willing to have my testimonial used but do not use my name.

Signed: ______________________________________________  Date: ________________

Print Name: _________________________________________________________________

Witness: ____________________________________________________________________

Print Witness Name ___________________________________________________________

Revision History:
2.0 Nov 17, 2015: re-written for clients.
1.0 July 2007: written for training workshops.