Free Telehealth Mental Health (Teletherapy) Consent Form Template

Informed Consent for Telehealth Mental Health and Psychotherapy Services

Patient Informed Consent Documentation

Patient and Therapist Information

1. Nature and Purpose of Telehealth Therapy

Telehealth mental health (teletherapy) is the delivery of professional counseling, psychotherapy, or psychiatric services using secure, interactive video and audio technologies. Sessions are conducted in real-time, allowing you and your therapist to communicate face-to-face. Teletherapy can help address emotional, psychological, or behavioral challenges, but requires active participation and commitment. The virtual format is highly convenient but is not suitable for all clinical situations, particularly during acute mental health crises or when a higher level of intensive in-person care is indicated.

2. Emergency and Crisis Intervention Plan

Because your therapist is physically distant, we must establish a clear plan for managing mental health emergencies or safety concerns. (1) In a crisis: If you feel overwhelmed, are experiencing severe panic, or have thoughts of self-harm, you agree to immediately tell your therapist during the session, or contact the National Suicide Prevention Lifeline (988) or go to the nearest emergency room. (2) Therapist Action: If your therapist believes you are in immediate danger of harming yourself or others, they are legally and ethically required to initiate emergency procedures. This includes calling your local emergency services (911), contacting your local emergency contact listed above, or sharing your physical location with emergency responders.

3. Confidentiality and Mandatory Reporting Exceptions

4. Risks and Limitations of Virtual Therapy

5. Technology and Privacy Guidelines

To protect the privacy of your sessions, you agree to: (1) Conduct therapy from a private room where you cannot be overheard by family, roommates, or coworkers. (2) Turn off smart speakers or other listening devices in the room. (3) Do not allow others to enter the room during your session unless agreed upon with your therapist. (4) Use a secure, private internet connection. Avoid public or shared Wi-Fi networks.

6. Alternatives to Telehealth Therapy

7. Professional Licensing and Jurisdiction

Mental health professionals are licensed by individual states. The therapist must be licensed in the state where you are physically located during the call. You must confirm your physical state location before starting each session. If you travel out of state, you must notify the therapist, as they may not be legally permitted to conduct sessions while you are away.

8. Cancellation and Session Fees

Therapy sessions are billed per hour. If you do not show up for your telehealth appointment or cancel with less than 24 hours notice, you will be charged the clinic's standard late cancellation fee. These fees are not covered by insurance and are your responsibility.

9. Right to Withdraw Consent

You have the right to withdraw your consent to telehealth therapy at any time. Doing so will not affect your right to receive future in-person care at this practice, subject to clinician availability.

10. Patient Understanding and Questions

I confirm that I have read this document and understand the telehealth mental health services, the crisis backup plan, the boundaries of confidentiality, the licensing rules, and the late cancellation policy. All my questions have been answered.

11. Language Access Services

If English is not your primary language, a qualified interpreter is available at no cost. Please notify staff before your first session.

12. Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form.

13. Patient Authorization

I voluntarily consent to participate in telehealth mental health and psychotherapy services. I authorize the secure transmission of my communications, agree to follow the privacy guidelines, and agree to the crisis safety protocol.

Signatures and Verification