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Professional Counseling Informed Consent Form Template

Streamline the Consent Process for Your Clients

Ensuring your clients understand their rights and the risks of counseling is vital yet often challenging. This informed consent form template is designed for therapists and counselors who want to provide clarity and build trust with clients. It helps you outline risks, confidentiality policies, and the scope of services, ensuring compliance while protecting both parties. Enhance client understanding, streamline sessions, and foster a professional therapeutic environment. Explore how this template can support your practice by accessing the live version.

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Full name
Date of birth
Pronouns (for example: she/her, he/him, they/them)
Home address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email
Phone number
Preferred contact method
Email
Phone call
Text/SMS
No preference
Emergency contact full name
Emergency contact relationship
Emergency contact phone
Is it okay to leave a voicemail at the phone number provided?
Yes
No
Type of service you are seeking
Individual counseling
Couples counseling
Family counseling
Group counseling
Not sure yet
Briefly describe your primary concerns or goals
Areas of concern (select all that apply)
Please Specify:
I understand that counseling information is confidential except as required by law (for example, risk of harm, abuse or neglect, court order).
Yes
No
I consent to the creation and secure storage of counseling records.
Yes
No
I understand I may request access to my records.
Yes
No
I consent to de-identified case discussion for supervision and training purposes.
Yes
No
I consent to coordination of care with my other providers if needed.
Yes
No
Not applicable
Preferred method to receive documents or notices
Email
Secure online portal
Postal mail
In person
Not applicable
I consent to receive appointment reminders.
Yes
No
Preferred reminder method
Email
Text/SMS
Phone call
No reminders
I consent to receive text messages, understanding SMS may not be fully secure.
Yes
No
Telehealth consent: I agree to participate by secure video/phone when offered and understand the risks, benefits, and alternatives.
Yes
No
Location during telehealth sessions (address or general location)
In a crisis or emergency, I will contact 911 or local emergency services.
Yes
No
I understand participation is voluntary and I may pause or discontinue at any time.
Yes
No
I understand the potential benefits and risks of counseling have been explained to me.
Yes
No
I understand services are provided at no cost and no payment is required.
Yes
No
I agree to arrive on time and provide notice if unable to attend.
Yes
No
Do you need any accommodations to participate?
Yes
No
Prefer not to say
Please describe any accessibility needs or preferences
Cultural or language preferences
How did you hear about this service?
Healthcare provider
School
Community organization
Online search
Social media
Friend or family
Referral partner
Prefer not to say
Other
Please Specify:
Are you under 18 years old?
Yes
No
Parent/Guardian full name (if applicable)
Parent/Guardian phone
Relationship to client
Parent/Guardian consents to counseling services for the minor
Yes
No
Client full name
Client signature
Date
Counselor full name
Counselor signature
Date
By signing, I confirm I have read and understand this informed consent and agree to receive counseling services.
Yes
No
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Paper art illustration representing a professional counseling informed consent form template.

When to use this form

Use this form when you onboard new clients in private practice, a group clinic, or school-based services. It documents consent for therapy, explains risks and benefits, outlines fees and cancellation rules, and clarifies how you handle records. It is especially helpful for telehealth, couples, or family sessions where you must define who the client is and how information is shared. For privacy details, you can reference the Counseling confidentiality form. If you support clients in multiple regions, align wording with the Professional counselling informed consent form. Teams that also provide testing can keep policies consistent by pairing this with the Psychology informed consent form.

Must Ask Professional Counseling Informed Consent Questions

  1. Do you consent to assessment and counseling services, and understand the potential benefits, risks, and alternatives?

    This secures clear, informed permission to begin care. It sets expectations and reduces misunderstandings about what therapy can and cannot do.

  2. Do you understand how confidentiality works, including legal limits and how your records may be used or shared?

    Naming the limits (risk of harm, abuse, court orders) helps you decide what to disclose. It also builds trust around privacy practices; for a related overview, see the Psychology informed consent form.

  3. Do you consent to telehealth sessions when applicable, and understand the technology risks and your responsibilities?

    Covering telehealth up front prevents confusion and protects your privacy. It also documents your location and backup contact, which supports crisis response and licensure rules.

  4. Do you agree to the fee schedule, payment method, insurance use, and the cancellation/no-show policy?

    Clear money terms reduce disputes and improve collections. It also helps you plan care you can afford and choose payment options that fit.

  5. Who is your emergency contact, and do you authorize us to reach them if we have serious safety concerns?

    This enables timely support during risk of harm. It also clarifies consent for outreach so we can act quickly and ethically.

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