Form templates / Mental Health & Therapy
Teletherapy Consent Form
A teletherapy consent form has to establish something an in-person consent never needs to: where the client will physically be, and what happens if the call drops mid-session.
For therapists, counsellors and mental-health practices.
An emergency plan needs an address
In a room, you know where your client is. On a video call, if someone becomes acutely unwell you may not know which city they're in - and that makes calling for help impossible.
So this template asks for the address they'll be at during sessions and a local emergency contact, and explains why. It also agrees the technology-failure plan in advance: who calls whom, on what number, after how long. Deciding that mid-crisis is far too late.
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.
Edit it like a document, publish like a link
Add questions, remove questions, change the order and the wording, set your accent colour. When you save, the form is live at its own address - share it by link, QR code or a button on your site, and read the answers in your dashboard.
What this template asks
- Your name
- Date of birth
- Email address
- Phone number
- Address you'll usually be at during sessions
- Country and region
- Will you sometimes be somewhere else?
- Where will you take the session?
- I understand I'm responsible for finding a private space, and that others may overhear if I don't
- I'll use headphones where I can
- What will you use?
- How reliable is your internet?
- I agree to the plan above if the technology fails
- May sessions be recorded for your clinical record?
- I will not record sessions without agreeing it first
- Emergency contact - name, relationship and number
- Your doctor's practice and location
- I understand this is not an emergency service and know who to contact in a crisis
- I consent to receiving therapy online
More Mental Health & Therapy forms
Questions
Why does the client's location matter?
Two reasons: an emergency response has to be local, and in many jurisdictions a practitioner's licence only covers clients physically present in that jurisdiction. Ask, and ask again if they travel.
Can sessions be recorded?
Only with explicit, separate consent - and think hard about whether you need to. This template asks it as its own question rather than bundling it.
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 teletherapy consent form today
Start from this template and change anything you like. Free to begin.