TEMPLATE FOR THERAPISTS
Consent for Telehealth Services
Telehealth consent isn't just a signature on a platform agreement. It's documentation that your client understood the risks, knew your licensing limitations, had a safety plan for emergencies, and confirmed their physical location before every session. Most generic forms cover about half of that.
This one covers all of it—in language your clients can actually read before they sign.
This is a plain-language telehealth consent document for clients receiving any portion of their care via video, phone, or remote services. It's designed to be completed at intake and updated whenever your platform, licensing states, or procedures change.
It covers the benefits and limitations of telehealth honestly—including what can't be observed over a screen and when telehealth isn't the right fit. It explains your client's responsibilities clearly: where they need to be, what they can't do during a session, and why their location matters every single time. It includes a dedicated section on per-session location confirmation—which is a legal requirement in some states and a clinical best practice in all of them—because in an emergency, not knowing where your client is can matter enormously.
It also covers licensing and geographic limitations in plain terms, so clients understand why being in another state during a session isn't a small thing. There's a built-in accessibility and language access section, because equitable care includes making sure telehealth actually works for the people you serve. And emergency resources are embedded directly in the document—not tucked into a footnote.
Every placeholder is marked in red. Teal clinician notes flag platform-specific decisions, state licensing considerations, and where to customize based on your specific telehealth setup.You're offering telehealth with a consent form you downloaded years ago and haven't looked at closely since—and especially if any of these sound familiar:
You want clients to understand the no-recording rule, the location confirmation requirement, and the licensing limitations before the first session—not after something comes up
You've had a session interrupted by a tech issue and want a document that sets expectations about how that's handled
You work across multiple states or hold compact licensure and need a form that addresses geographic limitations clearly
You want emergency resources and crisis protocols built directly into your telehealth consent—not left to a separate document
You want to address accessibility and language access in your documentation, not just in your values statement
You believe informed consent means clients actually understand what they're agreeing to—and you want a form that reflects that
1. Download and open—The template is a .docx file. Open it in Microsoft Word or Google Docs.
2. Replace the red brackets—Fill in your practice name, telehealth platform(s), licensed states or jurisdictions, and contact information throughout.
3. Review the teal notes—Teal clinician notes flag platform-specific decisions, state licensing considerations, and optional additions based on your client population and practice setup. Read each one, make your choice, and delete the note before finalizing.
4.Add your crisis resources—The emergency resources section includes a placeholder for local and regional crisis lines. Fill these in before distributing.
5. Remove the clinician instruction page—This must be removed before sending to clients.
6. Save as a PDF—When your edits are complete, save a final version as a PDF before sending to clients or uploading to your EHR.
7. Update it when things change—If you add a new platform, change your licensed states, or update your emergency procedures, revisit this document. It should reflect your current practice, not the one you had when you first set it up.
8. Have it reviewed—Before distributing to clients, have your final version reviewed by your licensing board, malpractice carrier, and/or a licensed attorney. Telehealth law varies by state and continues to evolve.
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