Free template

Informed consent template for psychotherapy

By Albert Wong, PhD, Clinical Psychologist

Informed consent is the founding agreement of therapy: it tells a new client what they are entering, what you promise, and where the promises end. A good one is readable — a client should be able to actually understand it, not just sign it. This template covers the sections nearly every psychotherapy consent needs, in plain language, with placeholders for the choices that are yours to make.

A starting point, not a finished document. Consent requirements vary by state and by profession — confidentiality exceptions, records access, minor consent, and disclosure rules all differ. Have your attorney and your licensing board's current rules review your final version before you use it with clients.

The template

Plain text — paste into any EHR or document

[PRACTICE NAME]
Informed Consent for Psychotherapy

Welcome. This document describes how therapy at this practice works — what you can
expect from me, what I ask of you, and the policies we both agree to. Please read it,
ask me anything that is unclear, and sign at the end.

1. WHAT THERAPY IS
Psychotherapy is a collaborative process. It can bring real benefits — relief from
distress, better relationships, new understanding of yourself — and it also carries
risks: sessions can stir up uncomfortable feelings, and change in one area of life can
create strain in another. Progress depends on many factors, and I cannot guarantee a
particular outcome. I will discuss my approach with you, and you may ask at any time
how our work is going and why I am suggesting what I suggest.

2. CONFIDENTIALITY AND ITS LIMITS
What you share in therapy is confidential. I will not release information about you
without your written authorization, except in situations where the law requires or
permits disclosure, which generally include:
   a. If I believe you are at serious risk of harming yourself or someone else;
   b. If I have reason to suspect abuse or neglect of a child, elder, or dependent
      adult, which I am required to report;
   c. If a court orders the release of your records;
   d. As needed for billing, insurance claims, or payment processing, limited to the
      minimum information necessary;
   e. In professional consultation or supervision, where I do not reveal your identity.
The exact scope of these exceptions is set by law in the state where I practice, and
I am glad to discuss them with you.

3. COMMUNICATION BETWEEN SESSIONS
The best way to reach me between sessions is [phone / secure portal / email]. I check
messages [frequency] and generally respond within [timeframe] on business days. Brief
scheduling messages are free; calls or correspondence beyond [number] minutes are
billed at my prorated hourly rate. I do not accept friend or follow requests from
current or former clients on personal social media, to protect your confidentiality.

4. FEES AND PAYMENT
My fee is $[amount] per [length]-minute session, due at the time of service unless we
agree otherwise. Other services — report writing, letters, coordination with other
providers beyond brief contacts, requested records preparation — are billed at
$[amount] per hour, prorated. Fees are reviewed [annually], and I will give you at
least [30] days' written notice before any change.

5. CANCELLATIONS AND MISSED SESSIONS
Your appointment time is reserved for you. My cancellation policy is described in a
separate document, which you will also sign; in short, cancellations with less than
[24/48] hours' notice and missed sessions are charged [fee], and insurance cannot be
billed for missed sessions.

6. EMERGENCIES
I do not provide 24-hour crisis coverage. If you are in immediate danger, call or text
988 (Suicide and Crisis Lifeline, US), call 911, or go to the nearest emergency room.
Then let me know what happened, as soon as it is safe to do so, so we can follow up
together.

7. YOUR RECORDS
I keep a clinical record of our work. You generally have the right to see your record
or receive a copy, subject to the law that applies where I practice; if reviewing it
together would be helpful, I encourage that. Records are retained and disposed of as
required by law and my licensing board.

8. TELEHEALTH
If we meet by video or phone, a separate telehealth consent describes how those
sessions work, including their privacy limits and our plan for technical failures and
emergencies.

9. ENDING THERAPY
You may end therapy at any time, and no explanation is required — though I encourage a
closing session when possible, because good endings are part of good treatment. If I
believe I am no longer the right fit for your needs, I will tell you directly, give
you reasonable notice, and offer referrals so your care can continue.

10. QUESTIONS AND CONCERNS
If something about our work troubles you, please tell me — repairing ruptures is often
where therapy does its best work. You also have the right to contact my licensing
board with concerns: [board name and contact information].

CONSENT
I have read this document, had the chance to ask questions, and agree to enter
psychotherapy under these terms.

Client signature: _______________________________    Date: ______________

Client name (printed): ___________________________

Therapist signature: _____________________________    Date: ______________

[Therapist name, credentials, license number]

How to use it

Fill in every bracketed placeholder — an unfilled placeholder in a signed consent is worse than no clause at all.
Read it aloud once. Anywhere you stumble, a client will too; reword it in your own voice.
Keep the cancellation policy as a separate signed document (this consent just points to it) — the cancellation policy generator drafts that one.
Add profession- and state-specific sections your reviewer flags: mandatory disclosure language, notice of privacy practices, minor-consent provisions.
Have the attorney and board-rules review done before the first client signs, and re-review after any major rule change.

Common questions

Is a written informed consent legally required?

For most licensed mental health professionals, yes — some form of informed consent is required by licensing board rules, state law, or both, and written consent is the standard way to document it. The specifics (what must be included, whether minors can consent, electronic signature rules) vary by state and profession, which is exactly why this template needs review by your attorney and your board before use.

Can I just use this template as-is?

No — treat it as a well-organized first draft. It covers the sections most consents need, but the confidentiality exceptions, records rules, and fee disclosure requirements in your state may differ from the general language here. Have an attorney familiar with your state and your licensing board rules review the final version. That review typically costs far less than the problem it prevents.

How often should clients re-sign the consent?

Once at intake, and again whenever the terms materially change — a fee increase, a new communication policy, a move to telehealth. Some practices re-consent annually as a matter of hygiene. Keep every signed version in the record, not just the latest one.

Can consent be signed electronically?

Generally yes — electronic signatures are widely accepted for this kind of agreement, and most practice management systems support them. Confirm any profession-specific rules in your state, and make sure the signed copy is stored in the client record either way.

What are the limits of confidentiality I must disclose?

The core set is danger to self or others, mandated abuse and neglect reporting, and court orders — plus the routine disclosures for billing and consultation. But the precise triggers and duties (for example, duty-to-warn rules) differ significantly from state to state, so this template states them generally and your final version should reflect the law where you practice.

Related tools

Practice Harbor — an EHR built by a psychologist — sends consent documents to clients for electronic signature and keeps every signed version in the chart.

More free templates

Browse the full template library → · See our free practice tools →

This template is general information, not legal advice. Requirements differ by state and profession — have your attorney and your licensing board's rules review your final version before use.