TEMPLATE FOR THERAPISTS
Telehealth Emergency & Safety Procedures
When a crisis happens during an in-person session, you're in the room. You can observe, intervene, stay with your client while help is called. Telehealth removes all of that. If a connection drops mid-crisis, if a client becomes unresponsive, if you need to dispatch emergency services to someone whose location you don't know—none of that has a good outcome without a plan established in advance.
This document is that plan.
This is a dedicated telehealth emergency and safety procedures document—designed to be completed at intake by every telehealth client and updated whenever key information changes. It is not a telehealth consent form. It is a crisis protocol—established before anyone needs it.
It collects the client's physical address and nearest cross-street, with an explicit agreement to confirm location at the start of every single session—because in a telehealth emergency, not knowing where your client is can be the difference between help arriving and help not arriving. It designates a primary and secondary Emergency Contact Person, with a built-in verification step and a "for practice use only" section to document that the ECP has been confirmed and is willing to serve in that role.
It explains—clearly, in plain language—what the clinician will do if a crisis occurs during a session, what happens if the connection drops while safety concerns are present, and when telehealth is no longer clinically appropriate and a higher level of care needs to be facilitated. It addresses interstate and travel considerations, because emergency services are location-specific and a client in a different state during a session changes how a crisis response works.
It also includes a safety information section where clients can voluntarily document relevant medical history, current medications, psychiatric hospitalization history, accessibility needs, and their existing safety plan—so that if emergency services are contacted, the clinician has something to give them.
Both client and clinician sign it. Every placeholder is marked in red. Teal clinician notes flag local resource decisions, state licensing considerations, and documentation requirements.You offer telehealth and your current intake process doesn't include a dedicated crisis protocol—and especially if any of these sound familiar:
You've never explicitly documented what you'll do if a connection drops while a client is in distress
You don't have a process for confirming client location at the start of every session—or you do it informally but haven't documented it
Your clients have designated an emergency contact somewhere in their intake paperwork but you've never verified that person is willing and able to actually respond
You work with clients who travel, live in different states, or are sometimes in unfamiliar locations during sessions—and you want a protocol that accounts for that
You want a document that tells clients honestly what telehealth can and can't do in a crisis—before they're in one
You believe that safety planning for telehealth clients deserves its own document, not a paragraph buried in your consent form
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, business hours, licensed states, clinician contact information, and any local or regional crisis resources for your area.
3. Review the teal notes—Throughout the document, teal clinician notes flag decisions to make—including local crisis resources, interstate licensing considerations, and how to handle clients who have no emergency contact. Read each one, make your choice, and delete the note before finalizing.
4. Add local crisis resources—The emergency resources section includes a placeholder for local crisis lines, mobile crisis teams, and community mental health centers. Fill these in—local resources are often more actionable than national lines.
5. Remove the clinician instruction page—This must be removed before sending to clients.
6. Complete it at intake—then keep it current—This document is only useful if the information in it is accurate. Build ECP verification into your intake process and add an update prompt to your annual check-in. The Annual Update Questionnaire in this suite includes a contact update section for exactly this reason.
7. Both clinician and client sign it—Unlike most intake forms, this one includes a clinician signature line. Use it.
8. 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.
9. Have it reviewed—Before distributing to clients, have your final version reviewed by your licensing board, malpractice carrier, and/or a licensed attorney. Telehealth emergency protocols and interstate licensing requirements vary by state and continue to evolve.
SAVE WITH BUNDLES
Complete Your Paperwork Toolkit
Other templates clinicians typically reach for alongside this one.
Bundle name
Bundle description
$
#NUM
#NUM
templates included