Informed Consent Form for Teletherapy Templates (PDF & Word Doc)

Providing therapy via telehealth introduces a set of clinical, legal, and logistical considerations that in-person practice does not — and clients have a right to understand those considerations before their first virtual session begins. Our Informed Consent for Teletherapy template gives clinicians a complete, written, signed document that establishes what telehealth is, what its benefits and limitations are, what the client’s responsibilities are, and what happens in an emergency — creating a clear record that protects both the client and the clinician from the first session forward.

Our Informed Consent Form for Teletherapy Templates are available as an editable Word document, fully customizable to reflect your practice name, platform, state licensure, and specific telehealth policies before use, and a fillable PDF. It is designed for outpatient mental health and counseling practices providing individual, couples, or family telehealth services.

What Our Teletherapy Consent Form Covers

Our template addresses every component of telehealth informed consent that HIPAA guidelines, professional ethics codes, and state licensing boards require — organized into clearly labeled sections:

• What telehealth is — a plain-language explanation of telehealth services and how they differ from in-person care, including a statement that telehealth is optional and that alternatives including in-person services and referral are available
• Platform and technology requirements — the specific telehealth platform used by the practice, technical support contact information, device and internet requirements, and a recommendation that clients test their technology before the first session
• Electronic communications — how routine scheduling and administrative communications occur outside of sessions, which channels are appropriate for what purposes, and the security limitations of standard email and text messaging
• Backup communication plan — primary and backup phone numbers for use if a session is disrupted, and the procedure for reconnecting or rescheduling if the session cannot continue
• Benefits and risks of telehealth — a balanced disclosure of the clinical benefits of telehealth alongside its specific risks and limitations, including reduced ability to observe nonverbal cues and limited capacity for immediate in-person intervention
• Confidentiality and recording — confidentiality protections under HIPAA and state law, client privacy responsibilities during sessions, and a comprehensive recording prohibition covering screenshots, screen recordings, and social media sharing
• Emergencies and crisis situations — explicit crisis resources including 911, the 988 Suicide and Crisis Lifeline, and the Crisis Text Line, along with fields for the client’s current physical address and emergency contact information
• Licensure and jurisdiction — the clinician’s state licensure, the requirement that clients disclose their physical location at the start of each session, and interstate compact authorization if applicable
• Client rights and responsibilities — a clear summary of what the client is entitled to and what they agree to as a condition of receiving telehealth services
• Fees and insurance — billing parity with in-person services, insurance coverage verification responsibilities, and the standard cancellation policy as applied to telehealth appointments
• Clinical appropriateness — the clinician’s ongoing authority to determine whether telehealth remains appropriate and the process for transitioning to in-person services or a higher level of care if needed
• Location verification initials — a dedicated initialing section in which the client acknowledges their location disclosure obligations, jurisdiction limitations, and recording prohibition
• Consent initials and signature block — individual initials for each core consent element followed by full client and clinician signatures, creating a complete authenticated record
• Minor client section — a separate consent block addressing the unique considerations of telehealth with minors, parental monitoring restrictions, confidentiality parameters, custody documentation requirements, and parent or guardian initials and signature

How Our Template Is Used in Practice

Our teletherapy consent form is completed before the client’s first telehealth session — typically as part of the initial intake documentation packet. The client reviews the form, completes the initialing sections, signs, and receives a copy. The signed original is filed in the clinical record.

Additional use cases include:

• Transitioning existing in-person clients to telehealth — when a client who previously received in-person services begins receiving telehealth services, a new telehealth consent establishes the updated terms of service
• Clients who travel or relocate — the location verification section and jurisdiction language address the specific documentation requirements that arise when a client may be located in a different state during sessions
• Annual intake packet reviews — our template should be reviewed annually and updated when the practice’s telehealth platform, licensure status, or state-specific telehealth regulations change
• Training clinics and supervised practice — the template can be adapted to reflect supervision disclosure requirements in telehealth training contexts

Practice Benefits

• Creates a complete signed record of telehealth informed consent that satisfies HIPAA requirements and professional ethics standards before the first virtual session
• Addresses the specific legal and clinical considerations of telehealth that standard in-person informed consent forms do not cover — including jurisdiction, emergency location protocols, technology requirements, and recording prohibition
• Reduces liability risk by documenting the client’s understanding of telehealth’s benefits, limitations, and their responsibilities as a telehealth participant
• Provides a dedicated minor client consent section that addresses the unique ethical and clinical considerations of delivering telehealth services to adolescent clients
• Editable Word document format allows practices to customize platform information, licensure details, state-specific requirements, and contact information before use

A Note on Clinical Judgment and Cultural Sensitivity

Our teletherapy consent form documents the client’s understanding and agreement at a point in time. Technology access, private space availability, and comfort with virtual communication can vary significantly based on a client’s housing situation, family environment, or socioeconomic circumstances — and can shift across the course of treatment. Clinical judgment should guide how telehealth is discussed with each client, and cultural competence should inform how barriers to telehealth participation are addressed without pathologizing practical limitations that are environmental rather than clinical.

References

• American Psychological Association. (2021). Guidelines for the Practice of Telepsychology. American Psychologist, 68(9), 791–800.
• National Association of Social Workers. (2021). NASW, ASWB, CSWE, and CSWA Standards for Technology in Social Work Practice. NASW Press.
• U.S. Department of Health and Human Services. (2013). The HIPAA Privacy, Security, and Breach Notification Rules. Office for Civil Rights.
• Zuckerman, E. L. (2015). The Paper Office for Mental Health Professionals: Forms, Guidelines, and Resources to Make Your Practice Work Legally, Ethically, and Profitably (5th ed.). Guilford Press.