About this template
An Online Therapy Consent Form is an essential legal and ethical document used by mental health professionals, counselors, and telehealth providers to secure explicit permission from patients before beginning virtual therapy sessions. This template establishes clear communication regarding the nature of teletherapy, potential technological limitations, confidentiality boundaries, and emergency protocols.
By gathering structured patient details and formal acknowledgment of practice policies, practitioners protect both client rights and professional liabilities. Collecting this information digitally before the first session streamlines intake, ensures compliance with clinical standards, and respects patient autonomy by making terms transparent and easy to review.
Key features
- Secure explicit, documented agreement before telehealth sessions begin
- Outline session confidentiality limits and privacy policies clearly
- Collect emergency contact details and local support resources
- Gather digital signatures and date stamps effortlessly
- Streamline the remote client intake process in one step
Use cases
- Licensed therapists launching or expanding a virtual private practice
- Online counseling clinics onboarding new telehealth patients
- Mental health facilities establishing telepsychology treatment terms
What this form collects
- Patient Full Name (Short answer)Enter your first and last name as the client receiving services.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Email Address (Short answer)We will use this address to send session links and appointment updates.
- Phone Number (Short answer)Provide a reliable phone number where we can reach you if connection issues arise.
- Current Physical Location During Sessions (Short answer)Enter the city and state/address where you will be physically located during our video calls (required for emergency dispatch purposes).
- Emergency Contact Name & Phone (Paragraph)Provide the name and phone number of a trusted local person we can contact in case of a mental health emergency.
- Telehealth Understanding & Risks (Multiple choice)Do you understand that online therapy involves both potential benefits and risks (such as technical interruptions or privacy breaches outside our control), and do you agree to participate?
- Confidentiality & Limits of Privacy (Multiple choice)Do you acknowledge that therapy sessions are confidential, with standard legal exceptions such as imminent risk of harm to self or others, child abuse, or elder abuse?
- Recording Policy Agreement (Multiple choice)Do you agree that neither the client nor the therapist will record audio or video of therapy sessions without explicit mutual written consent?
- Consent Status (Multiple choice)By selecting 'I Consent' below, you verify that you have read, understood, and agreed to the online therapy policies outlined above.
- Electronic Signature (Full Name) (Short answer)Type your full legal name as your electronic signature.
- Date of Signature (Date)Enter today's date.
FAQ
What is the purpose of an online therapy consent form?
It ensures that clients understand the unique nature of telehealth—including technological risks and privacy boundaries—before committing to virtual counseling sessions.
Can I customize the terms and conditions in this template?
Yes. Once you copy the template to your Google Drive, you can easily edit the text to reflect your specific practice policies, fees, and cancellation rules.
Is this form suitable for minors receiving therapy?
You can modify the template to include a section for parental or guardian consent if you treat underage clients.
How do clients sign the form electronically?
Clients can type their full name and submit the date in the required fields, serving as a formal digital acknowledgment of your practice policies.
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.