Form templates / Mental Health & Therapy
Informed Consent for Therapy Form
An informed consent for therapy form has one section that matters more than the rest: the limits of confidentiality. A client should know before they speak, not afterwards.
For therapists, counsellors and mental-health practices.
Say when confidentiality would be broken, in plain words
Confidentiality in therapy is not absolute, and every client deserves to know the exceptions before the first session - risk to themselves, risk to others, safeguarding, a court order, and clinical supervision.
Most consent forms bury this in a paragraph of professional language. This template lists each exception as its own short sentence and asks the client to acknowledge them. That's not defensive practice - it's what makes consent informed.
Say what they're agreeing to, in plain words
A consent form that nobody reads protects nobody. The statements in this template are short, specific and separate - so ticking one is a real decision rather than a formality.
Edit the wording to match what you actually do. It should sound like your practice, not like a legal template.
Ask gently, and hold it carefully
A first contact form in this field is often written by someone who has been putting it off for months. Short, plain and unintimidating matters more than thorough - you can ask the rest once there's a relationship.
What it must not do is feel surveilled. These pages carry no analytics, no third-party scripts and no cookie banner, and responses go only to the address you nominate.
Digital, dated, and searchable
Every response is stored with the date and time it was submitted, and the whole set exports as a spreadsheet. Finding one person's answers takes seconds rather than a filing cabinet.
Yours to change, immediately
Nothing here is fixed. Rewrite a question, reorder them by dragging, add your brand colour, delete half of it. Save and the live form updates - there's no separate publish step and no deploy to wait for.
What this template asks
- Your name
- Date of birth
- Email address
- Emergency contact - name, relationship and number
- Your doctor's practice
- I understand the limits of confidentiality described above
- I understand my case may be discussed anonymously in supervision
- I agree that my doctor may be contacted if there is serious concern for my safety
- I understand notes are kept and how long for
- May I contact you by email?
- I understand the fees and how to pay them
- I understand the cancellation policy
- I am attending voluntarily and understand I can stop at any time
- I understand therapy can be difficult at times and that no particular outcome can be promised
- I consent to beginning therapy
- Anything you'd like to ask before we start?
More Mental Health & Therapy forms
Questions
Does this meet my professional body's requirements?
It covers the elements most bodies require, but wording and specifics vary by profession and jurisdiction. Adapt it with reference to your own code of ethics and, where appropriate, your supervisor or indemnifier.
Should supervision be mentioned?
Yes, and it surprises clients if it isn't. Explaining that anonymised material is discussed in supervision is honest and almost never a problem when said in advance.
Is this legal advice?
No. The wording is a practical starting point, not a legal document - have your own adviser check anything you rely on, especially where health, minors or money are involved.
Is a tick box a valid signature?
In many places a clear, dated, affirmative action is accepted, but it depends on your jurisdiction and what you're doing. If you need a drawn signature, print the response and sign it, or take the form as the pre-appointment record.
Can I keep a copy for the person who filled it in?
Yes - they see a confirmation on screen, and you can turn on an email so a copy of each submission lands in your inbox for your records.
Is this confidential enough for therapy enquiries?
Pages are encrypted in transit and responses stay in your account, going only to the recipients you choose. Keep the form to what you need to make contact, say clearly that it is not for emergencies and where to go instead, and check your professional body's guidance on electronic records.
Publish your informed consent for therapy form today
Start from this template and change anything you like. Free to begin.