About this template
This Teletherapy Consent Form template is designed for mental health professionals and clinics transitioning to or expanding their virtual care services. It provides a structured way to ensure patients understand the nature, risks, and limitations of remote therapy sessions before treatment begins. By using this template, practitioners can clearly outline their professional policies, confidentiality protocols, and emergency procedures, ensuring that both the provider and the patient are aligned on expectations.
Collecting informed consent is a critical step in professional practice. This form allows you to gather essential patient details, confirm their understanding of the therapeutic process, and obtain a formal acknowledgment of your service terms. It is built to be clean and professional, helping you maintain a high standard of patient communication while reducing the time spent on manual paperwork. Simply customize the terms to reflect your specific practice policies and share the link with your patients to begin your sessions with confidence.
Key features
- Clear, professional language for informed consent.
- Easily customizable to include your practice-specific policies.
- Collects patient signatures and emergency contact details.
- Mobile-friendly format for easy patient access.
- Centralized responses for organized record-keeping.
Use cases
Initial patient onboarding for virtual therapy sessions.
Updating annual consent agreements for existing clients.
Establishing clear boundaries for remote communication and emergency …
Establishing clear boundaries for remote communication and emergency protocols.
Documenting patient acknowledgment of teletherapy risks and benefits.
What this form collects
- Patient Full Name (Short answer)Please enter your legal first and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Understanding of Teletherapy (Multiple choice)I understand that teletherapy involves the delivery of services using interactive audio and video technology.
- Confidentiality and Privacy (Multiple choice)I acknowledge that while reasonable efforts are made to ensure privacy, teletherapy carries inherent risks to confidentiality due to the nature of internet-based technology.
- Emergency Procedures (Multiple choice)I confirm that I have provided my current location and an emergency contact, and I understand the procedures to follow in the event of a crisis.
- Emergency Contact Name (Short answer)Please provide the name of a person we can contact in case of an emergency.
- Emergency Contact Phone Number (Short answer)Include area code.
- Electronic Signature (Short answer)By typing your full name below, you are signing this consent form electronically and agreeing to the terms outlined above.
- Date of Signature (Date)Select the date you are signing this form.
FAQ
Why is a written consent form necessary for teletherapy?
It ensures the patient understands the unique aspects of remote care, including potential technical issues, privacy risks, and emergency procedures, which is essential for ethical practice.
Can I add my own practice policies to this form?
Yes. Once you copy this template to your Google Drive, you can edit, add, or remove any questions or text sections to perfectly match your specific practice requirements.
How do I ensure patient privacy when using this form?
Google Forms provides robust security features. Ensure you are using a secure Google Workspace account and follow your local organizational guidelines regarding data handling and patient information.
Is this form suitable for all types of therapy?
This template is specifically structured for teletherapy and mental health services, but it can be adapted for other telehealth disciplines with minor adjustments to the terminology.
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.