Telehealth Consent Form for Therapy: Template and Examples

A remote therapy hour can feel ordinary until the client moves to a different room, the platform drops, or a safety concern appears while the therapist does not know where the client is. A telehealth consent form for therapy makes those decisions visible before the first video call. It gives you a document to adapt and a conversation to have; it does not turn a generic blank into a jurisdiction-ready legal form.

Use the template above as your starting form and replace every bracket with the practice’s actual workflow. Then read the important sections out loud with the client. Do not promise privacy, emergency response, recording controls, or an alternative service that your practice cannot provide.

Educational guidance for US mental-health clinicians. This page is not legal advice, a board opinion, or a substitute for checking the rules that apply to your license, practice, payer, and the client’s physical location.

Start with the service you actually provide

Name the service, modality, session length, cadence, clinician credentials, and the client’s role in the agreement. The 2014 ACA Code of Ethics, Standard H.2.a says counselors explain the benefits and limitations of distance counseling and obtain consent before providing it.

Write the service in language a client can understand. If the remote service is an intake, individual therapy, group, or family session, say so. If a trainee, supervisor, interpreter, caregiver, or another person may be involved, name the role and how that person participates. Do not let a platform’s click-through terms stand in for your treatment agreement.

Explain the platform and privacy limits

Tell the client which platform you use, how they join, what device or connection they need, and what you do to protect the session. Describe the privacy steps you actually use: a private room, headphones when appropriate, screen locking, access controls, secure storage, or another concrete practice. Do not claim that any technology makes privacy absolute.

If your practice is a HIPAA covered entity or business associate, the HIPAA Privacy Rule’s confidential-communications provision, 45 CFR 164.522(b) and the administrative safeguards provision, 45 CFR 164.308 are federal reference points for privacy requests and safeguards. They do not answer every state privacy, licensing, or platform question, and they do not make every practice a HIPAA covered entity. Check the rule that actually applies to your practice.

Ask about the client’s setting without turning privacy into a test they can fail. A shared home, a car, a workplace, a public network, a caregiver, or a support person can change who may hear the session. Document the client’s preference and the practical plan when that matters to care.

Explain benefits, limits, and alternatives

Remote care may reduce travel, preserve continuity, and make access easier. It may also reduce some nonverbal information, depend on a working device and connection, create privacy risks, and make urgent response harder when you do not know the client’s location. Explain those tradeoffs without presenting telehealth as automatically better or worse than in-person care.

Tell the client what alternatives your practice really offers. That may be an in-person visit, telephone when clinically and operationally appropriate, a rescheduled appointment, a referral, or no alternative. If you cannot provide in-person care, write that plainly. The client can make an informed choice only when the options are real.

Confirm the client’s physical location

Ask where the client is physically located at the start of every remote session and record the answer in the chart. A familiar video link does not prove that the client is in the same state as last week. The ACA Code of Ethics, Standard H.1.b directs counselors using distance counseling to understand laws and regulations in both the counselor’s location and the client’s location.

A consent form can include a location field, but the field does not grant authority to practice. Before providing care, check the license, compact privilege, temporary authorization, board rule, and other requirements that apply to your profession and the client’s location. If the location changes during the session, pause and address the change before continuing.

Use this sentence when reviewing the form:

Build a location-specific emergency plan

A telehealth consent form should tell the client what happens if an urgent safety concern arises while you are remote. Record the client’s location, a callback number, the local emergency number, the nearest emergency department, a permitted emergency contact, and your actual procedure if the call drops. If your practice uses a crisis service or another response pathway, name it accurately.

The ACA Code of Ethics, Standard H.2.a identifies emergency procedures as part of distance-counseling consent. An emergency plan is not a promise that you provide crisis monitoring. Emosapien is not a crisis response tool, and a remote therapy form cannot replace local emergency services or a clinician’s safety assessment.

Reconfirm the plan when the client travels, changes their address, uses a different device or callback number, or reports a change in safety. Keep the plan easy to find while you are in session rather than burying it in a long intake packet.

Plan for technology failure

Tell the client what to do if the video freezes, audio becomes unclear, the platform fails, or the session becomes unsafe to continue. Put one primary backup and one stop condition in the form. For example, you might call a verified number once, attempt a backup platform only if it is already approved, and reschedule if the connection cannot be made private or clinically usable.

Do not assume a backup channel is private because it is familiar. Name the channel, confirm that it is part of your approved workflow, and explain what information you will or will not share there. Document whether the session ended, continued by another modality, or was rescheduled.

Ask separately about recording and tools

Do not hide recording in a general technology paragraph. State whether you record audio, video, screen content, or nothing. If you propose recording, explain the purpose, access, storage, retention, deletion, and the client’s choice. Use a separate permission process when your profession or jurisdiction requires it.

Technology that drafts notes, transcribes a session, or stores content deserves its own plain-language explanation. Name the tool you actually use, the role it plays, and what happens if the client declines. A vendor’s terms are not your informed-consent script. Review the workflow when you add, remove, or change a tool.

Document withdrawal and review

The client should know how to decline telehealth, refuse a recording or technology step, and ask to revisit the decision. State what withdrawal means in your practice: an alternative appointment, a different modality, a referral, a pause, or another real option. Do not promise continuity you cannot provide.

Consent is ongoing. Revisit it when the platform changes, the client moves, the service changes, a new person joins the care team, recording is proposed, privacy becomes difficult, or the client asks a question that changes the agreement. Document the review, the client’s questions, the answer, and any follow-up.

Filled review example

The following example shows how to turn the blank into a conversation. It is not a required fee, platform, emergency number, or policy for your practice.

Download the telehealth consent form template

The downloadable telehealth consent form template follows the same sections: service, platform and privacy, risks, location and emergencies, technology failure, recording, withdrawal, questions, and signatures. Adapt the blank before use and have counsel or a compliance-competent supervisor review it when your setting or jurisdiction calls for that review.

For the broader intake workflow, compare the therapy intake form templates. For the general counseling agreement, see the informed consent form for counseling. For location and license research before a cross-state session, use the interstate telehealth rules for therapists.

Emosapien can help you keep a reviewable note workflow for modality, client location, consent status, and follow-up questions. The Scribe Agent does not decide whether a state rule, license, compact privilege, payer policy, or emergency procedure applies. Keep that judgment with the clinician and the practice’s compliance process. If you want documentation support that stays in review, start a free trial.

References

• American Counseling Association. (2014). ACA Code of Ethics.
• Electronic Code of Federal Regulations. (2025). 45 CFR 164.308: Administrative safeguards.
• Electronic Code of Federal Regulations. (2025). 45 CFR 164.522: Rights to request privacy protection for protected health information.