About this template
A professional disclosure statement and informed consent form is an essential tool for counselors, therapists, and mental health professionals. It outlines the therapeutic relationship, practice policies, confidentiality guidelines, and potential risks or benefits of counseling, ensuring clients fully understand their rights before beginning treatment.
Traditionally managed via paper packets or clunky portals, this workflow can easily cause onboarding delays. By using this digital form template powered by Doc2Form, practices can seamlessly collect client acknowledgments and consent agreements online. The form gathers necessary contact information, emergency contacts, and required electronic sign-offs on any device.
Streamlining your intake process reduces administrative overhead and ensures you meet professional practice standards right from the start. Whether you operate an in-person clinic or a virtual telehealth practice, providing a clear, accessible consent form sets a transparent foundation for the therapeutic alliance.
Key features
- Collect client acknowledgments and informed consent online before the first session.
- Easily customize disclosure terms, practice policies, and fee structures.
- Gather emergency contact information and guardian signatures for minor clients.
- Compatible with all devices for seamless client completion from home or office.
- Instantly convert client responses into organized records for your practice management workflow.
Use cases
Private practice mental health therapists onboarding new psychotherap…
Private practice mental health therapists onboarding new psychotherapy clients.
Telehealth counseling organizations requiring digital consent before …
Telehealth counseling organizations requiring digital consent before virtual sessions.
School counselors and youth wellness clinics capturing minor and pare…
School counselors and youth wellness clinics capturing minor and parent/guardian authorizations.
What this form collects
- Client Full Name (Short answer)Enter your full legal name.
- Email Address (Short answer)We will use this address to send copies of your submitted documents and appointment updates.
- Phone Number (Short answer)Enter the best phone number to reach you.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Emergency Contact Name and Relationship (Short answer)Provide the name and relationship of someone we can contact in case of an emergency.
- Emergency Contact Phone Number (Short answer)Enter a reliable phone number for your emergency contact.
- Is the client a minor (under 18 years of age)? (Multiple choice)If yes, parent or guardian details and signature will be required.
- Parent / Guardian Name (If applicable) (Short answer)Enter the full name of the parent or legal guardian authorizing treatment.
- Professional Disclosure & Informed Consent Acknowledgment (Multiple choice)By checking below, you acknowledge that you have read, understood, and agreed to the professional disclosure statement, office policies, confidentiality limits, and terms of service.
- Client Electronic Signature (Short answer)Please type your full legal name as your electronic signature.
- Date of Signature (Date)Enter today's date.
FAQ
What is an informed consent form?
An informed consent form is a document that outlines the details of professional services, policies, risks, benefits, and client rights, ensuring clients understand what to expect before beginning treatment.
Why are informed consent and disclosure statements important?
They establish clear boundaries, protect both the client and the practitioner by documenting agreed-upon policies, and fulfill ethical and professional practice standards.
Can parents or guardians sign on behalf of minors?
Yes. This template includes dedicated fields to capture parent or guardian names, consent acknowledgments, and signatures when providing services to minor clients.
Can clients withdraw their consent after signing?
Yes, clients generally retain the right to discontinue services and withdraw consent at any time, which should be explicitly outlined in your practice's disclosure terms.
How can I customize this template for my specific practice?
Once you bring this template into Google Forms via Doc2Form, you can easily edit the disclosure text, adjust your fee schedules, add your practice logo, and modify required questions.
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.