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Informed Consent for Therapy template

A free informed consent template for therapists covering what therapy involves, limits of confidentiality, fees, communication, and telehealth. Review it against your board's rules, then send it online.

Informed Consent for Therapy

What therapy involves

Therapy is a collaborative process. Sessions are usually [50] minutes. Benefits can include relief from distress and better relationships, but therapy can also bring up uncomfortable feelings. Progress depends on your participation, and no specific outcome is guaranteed. You may end therapy at any time.

I understand what therapy involves *

Confidentiality and its limits

What you share in therapy is confidential and won't be released without your written permission, except when the law requires or allows it: <ul><li>There is a serious risk of harm to yourself or someone else</li><li>There is suspected abuse or neglect of a child, elder, or dependent adult</li><li>A court orders the release of records</li><li>Limited information is needed for insurance billing, if you use insurance</li></ul>

I understand confidentiality and its limits *

Fees and cancellations

The fee is $[XX] per session, due at the time of service. Sessions cancelled with less than [24] hours' notice may be charged [the full fee].

I understand the fees and cancellation policy *

Communication

Email and text are not fully secure. They are best for scheduling, not for clinical content. Between sessions, [Practice Name] may not respond right away. In an emergency, call or text 988 or call 911.

I agree to be contacted by

Telehealth (if applicable)

Video sessions use a secure platform. You agree to join from a private location in the state where your therapist is licensed.

I understand the telehealth terms

Signature

Client full name *

Parent or guardian name, if client is a minor

Signature — type your full legal name *

Date signed *

7 parts of a therapy informed consent

  1. What therapy involves
  2. Benefits and risks
  3. Limits of confidentiality
  4. Fees and cancellation
  5. How to reach you, and when
  6. Emergency resources
  7. Telehealth terms
What's included
  • I understand what therapy involves
  • I understand confidentiality and its limits
  • I understand the fees and cancellation policy
  • I agree to be contacted by
  • I understand the telehealth terms
  • Client full name
  • Parent or guardian name, if client is a minor
  • Signature — type your full legal name
  • Date signed
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This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.