Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Psychotherapy Informed Consent Form Template

Effortlessly Secure Client Consent for Your Therapy Practice

Navigating client consent can be challenging, but using the right template simplifies the process. This Psychotherapy Informed Consent Form Template helps therapists like you ensure clients fully understand their treatment, fostering trust and clarity. With essential sections for treatment details, risks, and confidentiality policies, you can streamline your paperwork, enhance client experiences, and keep everything organized with ease. Plus, it's compliant with WCAG standards for accessibility. Start using this template today and focus more on your clients!

Use this Template (FREE) Live Preview
Client full name
Date of birth
Email address
Phone number
Who is completing this form?
I am the client
I am the parent/legal guardian
Do you consent to receive appointment reminders?
Yes
No
I understand that email and SMS may not be fully secure, and I consent to their use for scheduling and reminders.
Yes
No
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Parent
Spouse/partner
Family member
Friend
Healthcare provider
Other
Please Specify:
I understand the nature and purpose of psychotherapy, including potential benefits and risks.
Yes
No
My participation is voluntary, and I may withdraw consent at any time.
Yes
No
I understand confidentiality and its legal limits (risk of harm, abuse, court order, or as required by law).
Yes
No
If I am in crisis or at imminent risk, I will contact emergency services or crisis hotlines.
Yes
No
I have received or been offered the Notice of Privacy Practices.
Yes
No
I understand these services are offered at no cost to me.
Yes
No
I consent to receive psychotherapy via telehealth when offered.
Yes
No
I understand telehealth may involve technical difficulties and privacy limitations.
Yes
No
I agree to be in a private, distraction-free location during telehealth sessions.
Yes
No
Preferred session format
In person
Telehealth
No preference
I understand the scheduling, cancellation, and no-show policy (for example, 24-hour notice where applicable).
Yes
No
Do you authorize the therapist to coordinate care with other providers as needed?
Yes
No
Typed signature (full legal name)
Date of signature
I voluntarily consent to psychotherapy under the terms above.
Yes
No
{"name":"Client full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Client full name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
paper art illustration featuring a psychotherapy consent form with writing tools for FormCreatorAI article

When to use this form

Use this consent form before a first therapy session in private practice, clinics, or telehealth. It fits adult clients, and for minors a parent or guardian signs too. Each adult in couples or family work should sign. The form explains goals, methods, risks, benefits, privacy limits, fees, and how you handle messages and cancellations. It aligns expectations, meets ethical rules, and protects both you and your client. For general counseling programs, you can also use the Therapy informed consent form. If you will share de-identified case details for teaching or publications, add a Case report consent form. Substance use programs that require screening can pair this with a Drug test consent form.

Must Ask Psychotherapy Informed Consent Questions

  1. Do you understand the purpose, methods, and possible risks and benefits of therapy, and do you consent to participate?

    This confirms informed consent and shows you explained treatment in plain language. It helps prevent misunderstandings and meets legal and ethical standards.

  2. Do you acknowledge the limits of confidentiality, including safety exceptions and legal requirements?

    Stating these limits upfront protects client safety and your compliance. It prepares clients for rare situations when information must be shared, such as risk of harm or a court order.

  3. What are your communication preferences for scheduling, reminders, and telehealth, and where may we leave messages?

    Clear preferences reduce missed appointments and protect privacy on phones, email, or portals. It also covers consent to text or email and sets boundaries for response times.

  4. Do you agree to the fees, insurance billing practices, and the cancellation or no-show policy?

    Written agreement prevents billing disputes and supports attendance. It helps you enforce policies fairly and lets clients plan their care and costs.

  5. Do you give or decline permission for session recording or use of de-identified details for education, and under what conditions?

    This protects client autonomy and reduces risk around supervision or training use. If you plan any publication or teaching, a separate consent may be required by your institution or board.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel