Free template

Telehealth consent template

By Albert Wong, PhD, Clinical Psychologist

Telehealth changes a handful of things that in-person consent never had to address: where the client is, what happens when the connection dies, and how you reach them — or help — in an emergency. This template supplements a general psychotherapy informed consent with exactly those pieces, and collects the three practical facts you need before the first video session: usual location, a reconnection phone number, and a local emergency contact.

A starting point, not a finished document. Telehealth rules — consent requirements, cross-state practice, platform standards — vary by state and profession and change often. 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 Telehealth Sessions

This document supplements your informed consent for psychotherapy and describes how
sessions conducted by video or phone work. Please read it, ask questions, and sign at
the end.

1. WHAT TELEHEALTH IS
Telehealth means receiving therapy through live video or phone rather than in person.
For many people and many concerns it is as effective as in-person care; for some
situations it is not the best fit, and if I believe telehealth is not serving you well
I will say so and we will discuss alternatives, including in-person care or a referral.

2. TECHNOLOGY AND PRIVACY
We will meet using [platform name], which encrypts our sessions. No technology is
perfectly secure, however, and telehealth carries privacy risks that in-person
sessions do not — interruptions, unauthorized access, and technical failure. You can
protect your own privacy by joining from a private space, using headphones, and using
your own device on a network you trust. I will conduct my side of every session from a
private location.

3. YOUR LOCATION
At the start of each session I will ask where you are, for two reasons: so I can send
help to the right place in an emergency, and because my ability to provide services
depends on where you are located — clinicians are generally authorized to practice
only in the state(s) where they hold a license or other authorization. Please tell me
in advance if you will be joining from somewhere other than your usual location,
especially from another state, so we can confirm whether we can meet.

4. EMERGENCIES
Because we are not in the same place, we need a plan:
   a. Your session location today and the nearest emergency room to it;
   b. A local emergency contact I may call if I believe you are in danger and cannot
      reach you: [name, relationship, phone];
   c. If you are in immediate danger, call or text 988 (Suicide and Crisis Lifeline,
      US) or call 911.
If a session raises serious safety concerns, I may ask you to move to in-person care
or a higher level of support.

5. IF THE TECHNOLOGY FAILS
If our connection drops and we cannot reconnect within [10] minutes, I will call you
at [phone number]. If we cannot restore the session, we will reschedule, and you will
not be charged for time we did not meet.

6. RECORDING
Neither of us will record a session — audio, video, or screenshots — without the
other's written consent.

7. FEES AND INSURANCE
Telehealth sessions are billed at the same rate as in-person sessions unless we agree
otherwise. If you use insurance, be aware that coverage for telehealth varies by plan;
you are responsible for confirming your own benefits, and I will help where I can.

8. CONSENT
I have read this document, had the chance to ask questions, and consent to receiving
services by telehealth. I understand I may withdraw this consent and request
in-person services or a referral at any time.

Usual session location (city/state): ____________________________________
Phone number for reconnecting: __________________________________________
Local emergency contact: ________________________________________________

Client signature: _______________________________    Date: ______________

Client name (printed): ___________________________

Therapist signature: _____________________________    Date: ______________

[Therapist name, credentials, license number]

How to use it

Name your actual platform in section 2, and confirm the vendor signs a business associate agreement.
Collect the location, phone, and emergency-contact fields at signing — a blank emergency contact is the most common gap in telehealth files.
Actually ask the location question at the start of each session, and note it. The consent promises you will.
Pair it with the general informed consent; it supplements rather than replaces it.
Have your attorney and board-rules review done before first use, and re-check cross-state practice rules whenever a client relocates.

Common questions

Do I need a separate telehealth consent, or can one paragraph in my main consent cover it?

A separate document is the safer practice. Telehealth adds material that deserves its own signature — emergency procedures tied to location, technology risks, a reconnection plan — and a separate consent lets you add telehealth for an existing client without re-signing everything. Some states and payers also expect telehealth-specific consent language, which your attorney can confirm.

Why do I have to ask where the client is at the start of every session?

Two reasons, both real. In an emergency you need a physical address to send help to — "at home" is not dispatchable if the client moved or is traveling. And licensure is generally tied to where the client is located at the time of service, so a client joining from another state can change whether you are authorized to see them that day. It takes ten seconds and it belongs in your note.

Can I see clients who travel to or live in another state?

Sometimes — but never assume. Authorization to practice generally follows the client’s location, and states differ widely on temporary-practice allowances, compacts, and registration options, all of which change over time. Before a client joins from another state, check the current rules for your profession in that state, and document what you found.

What happens if the video drops mid-session?

The consent should answer this before it happens, which is why this template includes a reconnection plan: try to reconnect for a set number of minutes, then fall back to a phone call at a number collected in advance. Deciding this in advance turns a rattling interruption — sometimes at a tender moment — into a minor logistics step.

Is my video platform "HIPAA compliant" enough?

Look for two things: the platform encrypts sessions, and the vendor will sign a business associate agreement (BAA) with you. A consumer video product without a BAA is generally not appropriate for therapy, even if the video quality is fine. Also honest: no platform removes the biggest practical privacy risk, which is someone overhearing the client’s side of the room — the private-space guidance in the consent does more work than the encryption details.

Related tools and guides

Practice Harbor — an EHR built by a psychologist — includes secure video sessions, so the platform named in this consent can be the same place your notes and scheduling already live.

More free templates

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

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