Telehealth Consent Form for Therapy: Template to Copy

Search for a telehealth consent form and most of what you'll find is one clinic's PDF, written for medical visits: a paragraph about technology risks and a line to sign. Therapy by video needs more than that. When a client is in crisis on a screen, what matters is whether you know where they are right now, who can get to them, and what happens if the call drops. Below is a complete telehealth consent form for therapy, written in plain words with one line per field, that you can copy and adapt. After it, each section is explained with the source behind it: HHS telehealth and HIPAA guidance, CMS where it applies, the APA telepsychology guidelines and the ACA Code of Ethics. You'll also find how the rules differ by state, a 30-second location check for the start of every session, and how this form fits with your general informed consent.

What a telehealth consent form is for

A telehealth consent form records that you explained how therapy by video or phone works, including its risks and your safety plan, and that the client agreed to it. The conversation is the consent; the form is the evidence that it happened.

The sources agree on the basics:

Even where a state doesn't require documented consent, a written form helps. AHRQ, the federal agency that publishes a sample easy-to-understand telehealth consent form, points out that clinicians can use a form's language during the conversation and as a checklist that nothing was missed (AHRQ: easy-to-understand telehealth consent form).

Separate form, or a section of your informed consent?

Either works. Some therapists put telehealth in their main consent document; our informed consent example for counseling does that in a short section. Others use a separate telehealth consent form, like the one below, because it goes into more detail, because not every client is seen by video, and because the location and emergency details change more often than the rest of the agreement.

If you use a separate form, don't repeat everything: the template below points back to your general consent for confidentiality, fees, records and complaints, so the two documents never contradict each other. The section on how the two fit together, further down, lists what goes where.

What every telehealth consent form should cover

Put HHS, the APA guidelines and the ACA code side by side and you get this list. The template covers all of it.

The telehealth consent form template (copy and adapt)

Copy the block below into your own document. Fill in or delete everything in square brackets, remove what doesn't apply (for example section 8, if you only see adults), and keep the numbering so you and the client can refer to sections by number. It is written in the first person for a solo private practice; a group practice can change "I" to "we" and list each clinician's license.

The template is long because it is complete, but each line is short, and most clients read it in a few minutes. The parts that cost money or limit privacy are in the general consent; this form is about how the sessions themselves work and what happens when something goes wrong.

What each section does, and the source behind it

1What telehealth is and how sessions work

HHS's Office for Civil Rights published a resource on explaining telehealth to patients in plain language. It suggests telling patients what telehealth is, which technologies you use, and the names of the vendors, with a link to their privacy practices (HHS OCR: educating patients about telehealth privacy and security). The APA guidelines add the communication tools you use (video, phone, chat, portals), the technical requirements, and your rules for messages between sessions, including how quickly you reply; the ACA adds anticipated response time and time zone differences (H.2.a).

The fee lines come from APA Guideline 2, which asks psychologists to discuss billing for telehealth before services start, including charges when a session is interrupted, fee adjustments for technology failures and who pays for data overages. Insurance is on the list because the ACA names "possible denial of insurance benefits" as part of distance counseling consent. Many payers cover video sessions, but coverage of phone-only sessions and the billing rules differ by plan, and the client should know that before the first bill.

2Benefits and risks

Both the APA guidelines and the ACA code ask for risks and benefits (APA Guideline 2(c); ACA H.2.a, H.4.a), and California's board makes it a rule: licensees must tell clients about "the potential risks and limitations" of telehealth when they start (16 CCR 1815.5(c)(2), covered in the state section below). Name real risks, not a vague line about technology. The template names specific ones: dropped calls, missed cues, being overheard, someone getting into their account, and slower help in a crisis.

The last two lines matter as much as the list. The ACA asks counselors to consider face-to-face services when distance counseling isn't working and, if they can't offer them, to help the client find appropriate services (H.4.d). The APA asks psychologists to keep judging whether telehealth is appropriate as treatment goes on (Guideline 2). Telling the client now that you'll raise it makes the conversation easier later.

3Privacy and security

Three things belong in this section: what the platform does, what you do, and what the client can do.

The line about information on the client's device reflects HHS's guidance: once health information reaches a patient's own phone or device, the provider isn't responsible for its privacy or security there. Saying so plainly helps a client decide where and how to join.

If you work in a practice or program that screens for, diagnoses or treats substance use disorder, HHS notes that you will need additional consent before you share information with other providers. Add that to this section if it applies to you.

4Your location and our emergency plan

This is the section that does the most work, and the one generic forms usually skip. HHS's guidance on emergency plans for telebehavioral health asks you to document, before the first visit (HHS: creating an emergency plan for telebehavioral health):

The reason for the local numbers is in one line of that page: "911 only works if you are in the same location as the patient." If you dial 911 from your office, you reach your own local dispatch center, not the one that covers your client's address. That is why the template asks for the 10-digit number of the police or sheriff that covers the client's usual address. Look it up yourself when you set up the plan, and again whenever the client joins from somewhere new.

APA Guideline 9 adds the client's phone number, and suggests that the names of other people at the client's location, the local medical facility and the local police department may also help. For children and teens, it asks you to identify a caregiver who is available during the session. If a client won't give the information you need for the emergency plan, the guideline asks you to document the refusal and consider whether you can offer telehealth safely. The template's last line, about rescheduling, is the practical version of that.

Two lines in the template need care:

5If the technology fails

The ACA lists "possibility of technology failure and alternate methods of service delivery" as part of distance counseling consent (H.2.a), and the APA asks for procedures for technical problems that interrupt services (Guideline 2(j)). APA Guideline 9 gives a common example: continue an interrupted video session by phone. Pick a number of minutes and stick to it: long enough for a client to rejoin, short enough that they aren't left waiting.

The two lines about a call that drops while the client is at risk come from HHS's emergency plan guidance, which says that if you believe the patient is in crisis when the connection fails, you should notify an emergency contact. Discuss this with the client when you go over the form, so a call from you to their sister after a dropped session isn't a surprise.

6Recording

All three ethics codes require permission before you record a session: the ACA (B.6.c), the APA Ethics Code (4.03, which requires permission from everyone recorded or their legal representative; APA Ethics Code) and the NASW (1.03(h)). Many therapists don't record at all. If you do, or if any feature of your software records or transcribes sessions, describe it in this section: what it captures, who can see it, where it is stored and when it is deleted. HHS counts technologies that record or transcribe a telehealth session as handling electronic health information, so they fall under the HIPAA Security Rule, and a vendor that stores recordings or transcripts for you needs a business associate agreement.

Recording law is state law, and it applies to clients as well as to you. California, for example, makes it a crime to record a confidential communication without the consent of all parties (California Penal Code 632); other states require only one party's consent. The template asks clients not to record without agreeing it with you first, and doesn't threaten anything. If a client wants a recording, for example to replay a relaxation exercise, talk about where the file will live and who might find it.

7Licensure and where the client can be

The ACA tells counselors they may be subject to the laws of both their own practicing location and the client's place of residence, and asks them to make sure clients know the legal limits on practice across state lines (H.1.b). APA Guideline 6 asks psychologists to know the rules in both places, including licensure, reporting duties and age of consent, and names the usual ways to practice across state lines: a license in both states, an interstate compact, or a state's temporary practice provision or telepsychology registry, if one exists.

The usual rule is that the session happens where the client is. California's board puts it directly: anyone practicing marriage and family therapy, educational psychology, clinical social work or professional clinical counseling by telehealth with a client physically located in California needs a California license or registration (16 CCR 1815.5(a)). HHS's page on licensing across state lines lists the ways to practice across states (a full license, temporary practice laws, reciprocity, compacts and telehealth registration) and adds one tip: verify the patient's location and get consent before the appointment (HHS: licensing across state lines).

Compacts make this easier, but they work differently:

The traveling line is the one clients forget. College students home for the summer, snowbirds and people on work trips may not think to tell you they're in another state. Asking at the start of every session catches it.

8Clients under 18

APA Guideline 2 asks psychologists to get assent from children and teens along with a parent's consent, and Guideline 9 asks for a caregiver who is available during the session in case of an emergency. The template names that adult and asks them not to listen in, because privacy at home is the hardest part of telehealth with young people. A teen in a shared apartment may need headphones, a closed door and a time when siblings are out.

HHS's consent steps include telling children and teens that they can share confidential information you won't pass on to their parents, and outlining the rare circumstances when you would. Be careful to promise only what your state allows: who can consent to a minor's therapy, and what parents can see, are set by state law, and under HIPAA a parent is usually the child's personal representative, with exceptions (HHS: personal representatives). The template points back to your general consent for those rules so you only write them once.

9Your rights

The ACA starts its telehealth consent standard with the client's freedom to choose whether to use distance counseling (H.2.a), and the NASW asks social workers to help clients who don't want remote services find other options (1.03(g)). California's telehealth law says agreeing to telehealth doesn't stop a patient from receiving in-person care during a course of treatment (B&P 2290.5(c)). The rights lines say all of that in plain words, including the honest answer if you only work online.

HHS's patient resource suggests telling patients they can file a privacy complaint with the HHS Office for Civil Rights, which is why that line is here as well as in your general consent.

10Signatures

The statements above the signature lines record what the client agreed to, section by section, so the location and emergency plan can't be missed. Three details are easy to forget:

The start-of-session location check

Location checks are where good intentions fade by the third month. A short, fixed routine keeps them going. California requires its board's licensees to verbally obtain and document the client's full name and present address at the beginning of each telehealth session (16 CCR 1815.5(d)(1)); the NASW asks social workers to verify identity and location (1.03(f)). Even where your state doesn't require it, the routine is what makes the emergency plan usable.

Here is how the note line reads for an invented client, Marcus, in his sixth session:

Telehealth by video. Client at his apartment in Denver, Colorado (address on file), alone, private room. Identity and address confirmed at start of session. Callback number confirmed. Emergency contact (brother) unchanged.

If you bill Medicare, the location also tells you how to code the visit: CMS asks for place of service 10 for telehealth in the patient's home and 02 for telehealth elsewhere (CMS Telehealth FAQ). Check each other payer's rules. Our DAP notes guide shows where the location and private-space lines go in a full progress note.

Telehealth consent law varies by state

Most of what you need to check is state law: whether consent must be written, what must be disclosed, where the client can be and what you must record each session. Here are three examples, each from the state's own published law.

What to check with your board

Your licensing board's website usually links to its statutes and rules. Your professional association's state chapter, your malpractice insurer's risk management line and a health care lawyer can help with the rest. HHS's own advice on its consent pages is to have your forms reviewed by a lawyer.

If you see Medicare clients

The CMS Telehealth FAQ doesn't set out a consent form, but Medicare's rules affect what you tell Medicare clients. According to the CMS Telehealth FAQ (updated October 2026):

How the telehealth form fits with your general informed consent

Think of the two documents as one agreement in two parts. Here is where each topic lives:

Send the telehealth form with the general consent before the first online session, and go over both together. Then return to the telehealth form, and use its "reviewed again" line, when:

Going over the form in the first video session

Sending the form ahead lets the client read it at home. Going over it on screen turns it into consent. A few minutes is often enough if you focus on five points:

An example note line, for an invented client we'll call Priya, at a first session by video:

Reviewed telehealth consent with client before beginning: platform and back-up phone, risks of telehealth, privacy at her end (joins from her home office, door closed; code word agreed), emergency plan (usual address in Columbus, Ohio confirmed; emergency contact her partner, release signed; local police and nearest emergency room on file), dropped-call plan (5 minutes, then phone), no recording, and her right to stop telehealth or move to in-person care. Client asked whether her employer's network could see the session; explained that she joins from her own device and home internet. Client signed electronically before the session.

Common telehealth consent mistakes

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions, session notes and a form library in one place. Here is where a telehealth consent form fits.

To check that your form matches what clients actually see, look at practice.tranqbay.health: its opening walkthrough ends on the booking confirmation a new client gets, which reminds them to find a quiet, private space and check their camera and mic before the call, and the sessions section shows the video session itself. Licensing, the client's location and your emergency plan stay your responsibility on any platform.

Frequently asked questions about telehealth consent forms

Before your next video session

Copy the template, fill in your state's details, look up the local emergency numbers for each client's usual address, and check the form against your board's rules (and with a lawyer, if you can) before anyone signs it. Then add the 30-second location check to the start of every session.

If you want online booking, encrypted video sessions, forms and session notes in one place, see how TranqBay works for private practice: you can look at a practice website template and the booking confirmation a new client sees before a first video session. If you're deciding whether to join, this page explains how joining TranqBay works.

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