Therapy Consent Form Template

CONSENT FOR THERAPY SERVICES

Date: Date

Therapist/Counselor: Therapist Name

Credentials: Licenses/Certifications License Number: Number Practice Name: Practice Name Address: Address Phone: Phone Email: Email

Client Information:

Name: Client Full Name

Date of Birth: DOB Address: Address Phone: Phone Email: Email Emergency Contact: Name and Phone

Parent/Guardian (if client is a minor):

Name: Name

Relationship: Relationship

1. NATURE OF THERAPY

Services Provided:

This consent is for Individual therapy/Couples therapy/Family therapy/Group therapy services.

Therapeutic Approach:

Description of therapeutic modality: e.g., Cognitive Behavioral Therapy, Psychodynamic, Solution-Focused, etc.

Purpose:

Therapy aims to help you:

• Address emotional and psychological concerns
• Develop coping skills
• Improve relationships
• Work toward personal goals
• Enhance overall wellbeing

Format:

• In-person sessions at Address
• Telehealth sessions via Platform
• Hybrid (combination)

2. SCOPE AND LIMITATIONS

I Understand:

• Therapy is a collaborative process
• Active participation is important
• Progress depends on many factors
• Results cannot be guaranteed
• Therapy may be uncomfortable at times
• It may take time to see progress

Not Provided:

• Emergency services (see Crisis section)
• Legal advice
• Medical treatment
• 24/7 availability
• Immediate responses to messages

Therapist Not Responsible For:

• Decisions I make
• Actions I take
• Outcomes outside of therapy

3. SESSION INFORMATION

Session Length: 45/50/60/90 minutes

Frequency: Weekly/Bi-weekly/Monthly/As scheduled

Recommended Duration of Treatment: X sessions or ongoing as needed

Location:

Office address or "Via telehealth platform"

Scheduling:

• Schedule via: Phone/Portal/Email
• Reminder sent: How/When
• Confirm or reschedule: X hours before

4. FEES AND PAYMENT

Fee Structure:

• Initial assessment/intake: Amount
• Individual session (Duration min): Amount
• Couples/Family session: Amount
• Group therapy: Amount
• Sliding scale: Yes/No - Income-based options

Payment:

• Due at time of service
• Methods accepted: Cash/Check/Credit card/HSA/FSA
• Late payment: Policy

Other Fees:

• Missed/late cancel sessions: Amount
• Report/letter writing: Amount per hour/document
• Court/legal involvement: Amount per hour
• Telephone calls over X minutes: Rate
• Record copying: Fee

Insurance:

• I do/do not accept insurance
• You are responsible for verifying coverage
• You are responsible for copays, deductibles, and non-covered services
• I may provide receipts for out-of-network reimbursement
• See insurance authorization (if applicable)

Outstanding Balance:

• Payment plans available: Yes/No
• Services may be suspended for non-payment
• Collections: Policy

5. CANCELLATION POLICY

Cancellation/Rescheduling:

• Requires 24/48 hours advance notice
• Notice given to: Phone/Email
• With proper notice: No charge, reschedule
• Without proper notice: Full session fee charged

Late Arrival:

• Session ends at scheduled time
• Full fee charged
• May be rescheduled if more than X minutes late

Therapist Cancellation:

• Adequate notice provided
• Session rescheduled at no charge

Emergencies and Illness:

Reviewed case-by-case with documentation

6. CONFIDENTIALITY

Your Privacy is Protected:

What you share in therapy is confidential, with the following exceptions required or permitted by law:

I Must Break Confidentiality If:

• You are a danger to yourself (suicide risk)
• You are a danger to others (homicide risk)
• There is reasonable suspicion of child abuse or neglect
• There is abuse of an elderly or dependent adult
• Court orders disclosure (subpoena may be challenged)
• You authorize release in writing

Other Disclosures:

• Consultation with other professionals (identifying information minimized)
• Supervision (if applicable)
• Billing/administrative staff (minimal necessary information)
• Insurance company (if you use insurance)

I Will Not:

• Acknowledge you as a client to others without permission
• Discuss your case socially or publicly
• Release records without your written authorization (except as noted above)

Group Therapy:

Other group members are asked to maintain confidentiality, but I cannot guarantee it.

Couples/Family Therapy:

There is no confidentiality between individuals in couples or family therapy. Information shared may be discussed.

7. MINOR CLIENTS (If Applicable)

If Client is Under 18:

Parent/Guardian Rights:

• Generally have legal right to information about child's treatment
• May request records
• May be involved in treatment decisions

Teen Confidentiality:

• To build trust, some confidentiality is beneficial
• Therapist may not share everything with parent
• Exceptions: Safety concerns, serious issues

Agreement:

General information shared with parent:

• Attendance
• Progress toward goals
• Recommendations

Not Shared Unless Safety Concern:

• Specific content of sessions
• Personal disclosures
• Other boundaries discussed

Parent/Guardian Agrees:

To respect boundaries that support treatment.

Age of Consent for Mental Health:

Per state law, minors aged Age+ may consent to own treatment in some cases.

8. COMMUNICATION BETWEEN SESSIONS

Telephone Calls:

• For scheduling and brief matters
• Non-urgent questions
• Not a substitute for sessions
• Calls over X minutes may be billed

Email/Text:

• For scheduling and brief communication
• Not for clinical/urgent matters
• Not guaranteed to be secure
• May not be checked daily
• Response within X business days

Emergencies:

Do NOT use email or text. See Crisis Procedures section.

Social Media:

• Therapist does not accept friend/follow requests from clients
• Do not contact therapist via personal social media
• Maintains professional boundaries

9. CRISIS PROCEDURES

Therapy is Not Emergency Services

In Case of Emergency:

• Call 911
• Go to nearest emergency room
• Call National Suicide Prevention Lifeline: 988 or 1-800-273-8255
• Call local crisis line: Local number
• Text Crisis Text Line: Text HOME to 741741

After Hours:

• I am/am not available for emergency calls
• If yes: Call Number and follow prompts
• If no: Use above emergency resources

Hospitalization:

If hospitalized, please have someone notify me (with your consent).

10. RECORDS AND DOCUMENTATION

Records Maintained:

• Assessment and treatment planning
• Session notes (brief summaries)
• Correspondence
• Billing records
• Release forms

Your Right to Records:

• You may request your records
• Provided per state law
• May be restricted if harmful (per therapist discretion and law)
• Fee for copying: Amount
• Time to fulfill request: X days

Records Retention:

• Maintained for X years per state law
• Then destroyed securely

Electronic Records:

• Stored securely with encryption
• HIPAA-compliant system

11. TELEHEALTH (If Applicable)

Telehealth Consent:

If using video sessions:

• Platform: Name - HIPAA compliant
• You need: Internet, device with camera/microphone, private location
• Risks: Technology failure, internet disruption, privacy concerns
• Benefits: Convenience, access, continuity of care
• Same confidentiality applies
• Same fees apply

You Are Responsible For:

• Secure internet connection
• Privacy of your location
• Appropriate backup plan if technology fails

See Separate Telehealth Consent (if more detailed)

12. SOCIAL/INCIDENTAL CONTACT

In Public:

I will not acknowledge you first to protect your privacy. You may acknowledge me if you choose.

Social Events:

Recommend avoiding attending same events when possible. May not interact extensively.

Purpose:

Maintain professional boundaries and your privacy.

13. TERMINATION OF THERAPY

Ending Therapy:

Either of us may terminate therapy.

I May Terminate If:

• You do not pay as agreed
• You have completed treatment goals
• You would benefit more from different treatment or provider
• We are not a good therapeutic fit
• There is a conflict of interest

You May Terminate:

At any time. Please discuss with me first if possible.

Termination Process:

• Ideally includes termination session
• Referrals provided if needed
• Records available per policy
• Outstanding balance due

Abandonment:

If you do not attend sessions for X weeks without contact, your case may be closed.

14. PROFESSIONAL CONSULTATION

I May Consult:

• With other mental health professionals about your case
• Identity protected
• To provide best care

Supervision (If Applicable):

I am under supervision by Name, Credentials. Your case may be discussed for training purposes.

15. LEGAL INVOLVEMENT

Court Involvement:

I prefer not to be involved in legal proceedings. If subpoenaed:

• I will assert privilege to protect your confidentiality
• If required to testify, billed at Rate
• Preparation time billed
• Travel time billed
• You are responsible for fees

Child Custody:

I do not provide opinions on custody matters.

Recommendation:

Avoid involving therapist in legal matters when possible.

16. RISKS AND BENEFITS

Potential Benefits:

• Reduced symptoms
• Improved coping skills
• Better relationships
• Increased self-awareness
• Symptom relief
• Personal growth

Potential Risks:

• Uncomfortable emotions during therapy
• Relationship stress as you change
• Symptoms may initially worsen
• Memories or feelings may surface
• Decisions about life changes
• No guarantee of desired outcome

I Understand:

The risks and benefits, and choose to proceed.

17. DUAL RELATIONSHIPS

Boundaries:

Our relationship is professional only.

I Will Not:

• Engage in social relationship with you
• Attend your personal events
• Accept gifts of significant value
• Provide therapy to friends, family, or colleagues
• Engage in any romantic or sexual relationship (unethical and illegal)

If Boundary Issues Arise:

Discuss with me or contact: Licensing board

18. CLIENT RESPONSIBILITIES

For Effective Therapy, Please:

• Attend sessions regularly and on time
• Pay fees as agreed
• Provide accurate information
• Participate actively
• Complete any homework/exercises
• Communicate concerns or questions
• Notify of any changes in medications or health
• Give feedback about therapy

19. COMPLAINTS AND GRIEVANCES

If You Have Concerns:

Please discuss with me first. I welcome feedback.

If Unresolved:

File complaint with: State Licensing Board Name Address: Address Phone: Phone Website: Website

Also May Contact:

• Insurance company (if applicable)
• Professional association
• Other relevant bodies

20. CONSENT AND AGREEMENT

I Acknowledge:

• I have read and understand this consent
• I have had opportunity to ask questions
• My questions have been answered
• I understand the nature of therapy
• I understand fees and policies
• I understand confidentiality and its limits
• I understand my rights
• I consent to treatment
• I received a copy of this consent
• I received Notice of Privacy Practices (HIPAA)

SIGNATURES:

Client:

I consent to therapy services as described above.

Signature: _______________________

Printed Name: Client Name

Date: _______________________

Parent/Guardian (If Client is Minor):

I consent to therapy services for the minor client named above.

Signature: _______________________

Printed Name: Name Relationship to Client: Relationship

Date: _______________________

Therapist:

I have discussed this consent with the client and answered questions.

Signature: _______________________

Printed Name: Therapist Name Credentials: Credentials

Date: _______________________