About this template
Providing mental health services remotely requires clear communication regarding the unique nature, benefits, and risks of virtual sessions. This Teletherapy Informed Consent Form template helps practitioners establish professional boundaries, outline confidentiality limits, and secure informed agreement before treatment begins.
The form collects essential client contact details while guiding the respondent through vital telehealth policies, including emergency protocols, technology limitations, and privacy considerations on digital platforms. Clients can review the terms and provide their acknowledgement and digital signature directly from any device.
Built for modern practices, this template streamlines intake workflows so clinicians can spend less time managing paperwork and more time supporting clients. By gathering structured acknowledgements upfront, practices ensure ethical compliance and maintain clear documentation for every virtual therapeutic relationship.
Key features
- Secure informed consent for remote mental health sessions in minutes.
- Outline telehealth limitations, risks, and confidentiality policies clearly.
- Collect client contact details and emergency contact preferences.
- Include digital signature and date tracking for legal compliance.
- Fully customizable to match your specific practice policies.
Use cases
Onboarding new private practice therapy clients for virtual sessions.
Transitioning in-person counseling clients to telehealth formats.
Securing annual consent renewals for ongoing telepsychology care.
Documenting client agreement for digital communication and video plat…
Documenting client agreement for digital communication and video platforms.
What this form collects
- Client Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Phone Number (Short answer)Primary phone number where you can be reached for sessions or emergencies.
- Email Address (Short answer)Where session links and practice updates will be sent.
- Emergency Contact Name & Phone (Paragraph)Provide a trusted local contact who can be reached in case of an urgent safety concern during a session.
- Understanding Telehealth Risks & Benefits (Multiple choice)Teletherapy allows mental health services to be delivered remotely, but it also carries risks such as technical interruptions or privacy breaches if unauthorized persons are nearby. Do you understand and accept these terms?
- Emergency Protocol & Crisis Situations (Multiple choice)Teletherapy is not suitable for acute crises or emergencies. If you are experiencing an immediate safety crisis, you agree to call 911 or go to the nearest emergency room. Do you acknowledge this policy?
- Confidentiality and Session Recording (Multiple choice)Sessions are confidential within legal limits. Neither the client nor the provider may record video or audio sessions without explicit written consent. Do you agree to maintain session privacy?
- Digital Signature (Short answer)By typing your full legal name below, you certify that you have read, understood, and agree to the teletherapy informed consent terms.
- Date of Signature (Date)Select today's date.
FAQ
What is a teletherapy informed consent form?
It is a specialized agreement that informs clients about the nature of virtual mental health treatment, covering technology risks, confidentiality limits, and emergency procedures before therapy begins.
Why is teletherapy consent different from in-person consent?
Virtual sessions introduce unique challenges regarding data privacy, internet connectivity, emergency handling when remote, and the technical limitations of video conferencing tools.
Can I customize the terms and conditions in this template?
Yes. Once you convert this template to Google Forms using Doc2Form, you can freely edit, add, or remove any clauses to align with your specific clinical guidelines and jurisdiction.
How do clients sign this form remotely?
Clients can open the form on any smartphone, tablet, or computer, read through the disclosures, type their legal name as a digital signature, and submit it instantly.
Where are client form submissions stored?
Submissions are saved directly to your secure Google Sheets connected to the Google Form, allowing you to easily review and reference client records.
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.