About this template
This informed consent template is designed for organizations, youth services, and healthcare providers who need to secure proper permission before engaging in remote communication via phone, text, or video platforms like Zoom or Doxy.me. Collecting clear acknowledgment of communication channels protects both the organization and the client by ensuring full transparency regarding privacy, scheduling, and remote service delivery.
The form covers individual status, communication channel preferences (text messages, voicemails, video calls), and includes specialized signature blocks for clients, parents or guardians, and agency representatives when applicable. Built with Doc2Form, this template replaces messy paper trails with a streamlined digital workflow, allowing respondents to review terms and submit their acknowledgments seamlessly.
Whether you operate a youth support program, counseling clinic, or community organization, this form ensures your remote communication practices are documented, ethical, and easy to reference when needed.
Key features
- Collect digital consent for text, phone, and video conferencing in one place.
- Include dedicated signature blocks for youth, parents, and agency staff.
- Clarify privacy and communication policies before remote sessions begin.
- Easily embed links to detailed privacy policies or terms of service.
Use cases
Youth support programs offering telehealth or remote counseling.
Community organizations coordinating virtual meetings and check-ins.
Mental health providers establishing guidelines for text and video co…
Mental health providers establishing guidelines for text and video communication.
What this form collects
- Participant Full Name (Short answer)Enter the full legal name of the youth or client receiving services.
- Date of Birth (Date)Enter your date of birth to verify age status.
- Are you 18 years of age or older? (Multiple choice)Select your current status. If under 18, parent or guardian consent will also be required.
- Text Message Consent (Multiple choice)Do you consent to receiving appointment reminders and updates via SMS text message?
- Phone and Voicemail Consent (Multiple choice)Do you consent to receiving phone calls and leaving voicemails regarding your appointments or services?
- Video Conferencing Consent (Zoom, Doxy.me, etc.) (Multiple choice)Do you consent to participating in video conferencing sessions for appointments and consultations?
- Client Electronic Signature (Short answer)Type your full legal name here to serve as your electronic signature indicating agreement to these terms.
- Today's Date (Date)Select today's date.
- Parent / Guardian Full Name (Short answer)Enter the full legal name of the parent or legal guardian.
- Parent / Guardian Electronic Signature (Short answer)Type your full legal name to authorize communication and services for the minor participant.
- Date of Parent Signature (Date)Select today's date.
FAQ
What is the purpose of this informed consent form?
It ensures that clients—and their parents or guardians when required—understand and agree to the terms of communicating via phone, text message, and video conferencing platforms.
Can I customize the specific communication platforms listed?
Yes, you can easily edit the form in Google Forms to add or remove video platforms, phone policies, or text messaging terms to match your exact program requirements.
How do electronic signatures work with this form?
Respondents type their legal name and date the submission as an electronic acknowledgment of consent. For formal document uploads, respondents can also paste links to signed paperwork.
Who should complete this form?
The form is typically filled out by the client or participant, along with a parent or legal guardian if the participant is under 18, prior to starting remote services.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.