Get Signed Teletherapy Consent Before the First Session

Document teletherapy benefits and risks, confidentiality limits, crisis resources, and HIPAA privacy acknowledgment in one simple online consent form.

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Teletherapy Video Counseling Session Informed Consent & Privacy Acknowledgment Form

Client Full Name

· · ·

Date of Birth

· · ·

Email Address

· · ·

Submit

The Teletherapy Video Counseling Session Informed Consent and Privacy Acknowledgment Form gives mental health providers a complete, ready-to-use way to prepare clients for online therapy. It collects client contact details, the physical address where sessions will take place, emergency contact information, and the client's preferred backup plan if a video connection drops. A clear consent section explains how teletherapy works, its benefits and risks, recording rules, licensure and location requirements, fees, and the client's right to withdraw consent at any time.

This template is built for licensed therapists, counselors, psychologists, social workers, group practices, and community mental health clinics that offer video sessions. Clients confirm they understand the limits of confidentiality, including mandated reporting duties. They also confirm that teletherapy is not a crisis service, with 911 and the 988 Suicide and Crisis Lifeline listed for emergencies. They agree to attend sessions from a private location, acknowledge receipt of your Notice of Privacy Practices, and choose whether to receive email or text reminders. A parent or legal guardian field covers clients who are minors.

Moving consent online saves time at intake and keeps your documentation consistent for every client. Instead of chasing paper forms or scanned PDFs, you receive signed acknowledgments digitally, ready to file with the client record. Customize the wording to match your state's regulations and practice policies, add or remove fields as needed, and share the form by link or email so clients can complete it from any device before their first appointment.

3 Pages

20 Questions

~7min To complete

Free No credit card needed

Field types singlecheckbox ×5 Full Name ×4 Date ×2 Phone ×2 Email Address Single Choice richtext Yes / No termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Client Information & Safety Plan 9 questions

Client Information & Safety Plan

1 Client Full Name * Full Name

2 Date of Birth * Date

3 Email Address * Email

4 Phone Number * Phone

5 Therapist / Counselor Name * Full Name

6 Physical Address Where You Will Attend Sessions * Address

7 Emergency Contact Name * Full Name

8 Emergency Contact Phone Number * Phone

9 If the video connection is lost and cannot be restored, I prefer to: * Single Choice

Page 2 Informed Consent for Teletherapy 4 questions

Informed Consent for Teletherapy

1 About Teletherapy: Sessions take place over a secure, HIPAA-compliant video platform instead of in person. Benefits & Risks: Teletherapy can offer convenience, access to care from home, and continuity of treatment. Risks include dropped connections, audio or video problems, fewer non-verbal cues, and possible unauthorized access despite encryption and other safeguards. Teletherapy may not suit every concern, and your therapist may recommend in-person care or a referral. Recording & Records: Neither you nor your therapist will record a session without the other's written consent. Sessions are documented in your confidential clinical record, just like in-person visits. Location & Licensure: Your therapist must be licensed where you are physically located. Please tell your therapist before joining a session from a different address. Connection Loss: If a session is interrupted, your therapist will try to reconnect. If that fails, they will follow the backup plan you selected. Fees: Standard session fees and cancellation policies apply. Please check telehealth coverage with your insurance provider. Your Rights: You may withdraw consent to teletherapy at any time and request in-person services or a referral. richtext

2 I understand the potential benefits and risks of teletherapy, including technology failures, session interruptions, and the possibility of a privacy breach despite reasonable safeguards. * singlecheckbox

3 I understand the limits of confidentiality. My therapist has a legal duty to disclose information to prevent serious harm to myself or others and to report suspected abuse or neglect of a child, elder, or dependent adult. * singlecheckbox

4 I understand teletherapy is not a crisis service. In an emergency, I will call 911, call or text 988 (Suicide & Crisis Lifeline), or go to the nearest emergency room. * singlecheckbox

Page 3 Privacy Acknowledgment & Signature 7 questions

Privacy Acknowledgment & Signature

1 I will attend sessions from a private, secure location where I cannot be overheard, and I will not record any session without my therapist's written consent. * singlecheckbox

2 I acknowledge that I have received and reviewed the Notice of Privacy Practices, which explains how my health information may be used and disclosed and my rights under HIPAA. * singlecheckbox

3 May we send appointment reminders and non-clinical messages by email or text? (These channels may not be fully secure.) * Yes / No

4 Parent / Legal Guardian Name (if client is a minor) Full Name

5 I have read and understand this Teletherapy Informed Consent and Privacy Acknowledgment and have had the opportunity to ask questions. I voluntarily consent to receive counseling via secure video, and I understand I may withdraw this consent at any time. * termsandconditions

6 Client Signature (or Parent / Legal Guardian if client is a minor) * Signature

7 Date Signed * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.