Love Lab Consent
My clinician has explained to me what the Gottman Love Lab (GLL) is and how it works and has answered my questions to my satisfaction. I give my consent to participate willingly in the Gottman Love Lab relationship assessment process, owned and operated by Affective Software Inc. (ASI) and The Gottman Institute (TGI). I understand that the information collected that I provide as part of this process may include but not be limited to intimate details of my personal life, family life, and sexual life, and may include information that I find embarrassing or upsetting. The information includes and may not be limited to video recordings. I understand that all of my personal information will be confidential to the full extent of the law and stored in a HIPAA-compliant platform. If I do not wish to be recorded, or if I wish to terminate recording, I understand that it is not only my right but also my responsibility to say so, either on the recording (to end it), in writing, or simply to refuse to participate. I understand that if I refuse to be recorded, I may not be able to participate in the GLL.

I understand that participation in the GLL is not therapy. Rather, GLL is a tool through which we gather information to render hypotheses that may be useful to understand the status of our relationship, including its particular strengths and challenges. To do so, our participation will require honest answers to intimate questions that may be difficult to discuss. In order to ensure the greatest honesty in this process to render reliable data, I agree that under no circumstances will I subject the information I provide to subpoena or disclose the information on this video or the existence of it for purposes of legal process. Should there be legal proceedings in which I am involved, neither I nor anyone acting on my behalf, including an attorney, nor any other person with whom I may consult, will seek from GLL, ASI, or TGI, to testify or to produce documents, opinions, recommendations, records, recordings, or any other form of evidence as part of, formed, created, or resulting from the GLL or ASI process for any legal proceedings or legal purpose.

Having agreed to the above, if for any reason, such as either person’s individual therapy, either party requests disclosure, it is understood that both parties must sign consent to release information pertaining to these records. I understand that if the video or other materials were subject to subpoena or court order, it is possible that they may be disclosed in ways and for purposes that cannot be predicted at this time. I agree that I shall hold GLL and ASI harmless as to any legal action including civil or criminal liability, as well as harmless as to any non-legal result that may occur, including any result that could be embarrassing to me, detrimental to my relationship or any position I hold, or harmful to my reputation.

Video Recording Data Policy Consent
I understand that video recording is a critical component of the GLL relationship assessment process and that ASI and TGI will use my video recordings and associated analysis to generate an assessment of my relationship. I understand that ASI and TGI will use the data collected to provide an assessment report to my therapist. I understand that all of my recorded videos will remain the property of my therapist and are confidential to the full extent of the law. I understand that any form of recording of PHI contained within the platform is prohibited. I understand that all my recorded videos are secured and stored in a HIPAA-compliant platform by ASI and TGI to protect my identity and to keep my data confidential. I understand that any recorded videos cannot and will not be downloaded, extracted from the platform, or duplicated in any way or fashion for any reason.

Electronic Consent
We each acknowledge that we have read, understand, and agree to the terms of this consent form, that each of us is of age and capacity and has the right and authority to contract in his/her/their own name, and that this consent shall be binding upon each of us and our respective heirs, legal representatives, and assignees. I give permission for my clinician to use my video recordings and analysis to generate an assessment of my relationship. I have been provided a copy of this agreement. I have had the opportunity to ask questions and to consult with an attorney if I wish to do so. If consent is provided through electronic signature or agreement, I understand that my electronic signature or agreement is intended by me to bind me to this agreement to the full extent of a written signature.