Telehealth Informed Consent
The sample which follows is one example of what might be included in an agreement for
Telehealth services. This form should be used in conjunction with a traditional Informed Consent
Agreement or Disclosure Statement. Therapist may adopt some or all of it to meet their
particular needs. This document is provided for informational and educational purposes only
and should not be considered legal advice.
TELEHEALTH CONSENT FORM
I, [Name of Patient] (Patient) hereby consent to engage in Telehealth with [Therapist’s Name,
License] (Therapist).
I understand that Telehealth is a mode of delivering health care services, including
psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis,
consultation, treatment, education, care management, and self-management of a patient’s
health care.
By signing this form, I understand and agree to the following:
1. I have a right to confidentiality with regard to my treatment and related communications
via Telehealth under the same laws that protect the confidentiality of my treatment
information during in-person psychotherapy. The same mandatory and permissive
exceptions to confidentiality outlined in the [Informed Consent Form or Statement of
Disclosures] I received from my therapist also apply to my Telehealth services.
2. I understand that there are risks associated with participating in Telehealth including, but
not limited to, the possibility, despite reasonable efforts and safeguards on the part of my
therapist, that my psychotherapy sessions and transmission of my treatment information
could be disrupted or distorted by technical failures and/or interrupted or accessed by
unauthorized persons, and that the electronic storage of my treatment information could
be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via
Telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am
responsible for using a location that is private and free from distractions or intrusions.
5. I understand that at the beginning of each Telehealth session my therapist is required to
verify my full name and current location.
6. I understand that in some instances Telehealth may not be as effective or provide the same
results as in-person therapy. I understand that if my therapist believes I would be better
served by in-person therapy, my therapist will discuss this with me and refer me to
in-person services as needed. If such services are not possible because of distance or
hardship, I will be referred to other therapists who can provide such services.
7. I understand that while Telehealth has been found to be effective in treating a wide range
of mental and emotional issues, there is no guarantee that Telehealth is effective for all
individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot
be guaranteed or assured.
8. I understand that some Telehealth platforms allow for video or audio recordings and that
neither I nor my therapist may record the sessions without the other party’s written
permission.
9. I have discussed the fees charged for Telehealth with my therapist and agree to them [or for
insurance patients: I have discussed with my therapist and agree that my therapist will bill
my insurance plan for Telehealth and that I will be billed for any portion that is the patient’s
responsibility (e.g. co-payments)], and I have been provided with this information in the
[Informed Consent Form or Name of Payment Agreement Form].
10. I understand that my therapist will make reasonable efforts to ascertain and provide me
with emergency resources in my geographic area. I further understand that my therapist
may not be able to assist me in an emergency situation. If I require emergency care, I
understand that I may call 911 or proceed to the nearest hospital emergency room for
immediate assistance.
I have read and understand the information provided above, have discussed it with my
therapist, and understand that I have the right to have all my questions regarding this
information answered to my satisfaction.
[For conjoint or family therapy, patients may sign individual consent forms or sign the same
form.]
______________________________________________ ______________________________
Patient’s Signature Date
______________________________________________
Patient’s Printed Name
Verbal Consent Obtained
Therapist reviewed Telehealth Consent Form with Patient, Patient understands and agrees to
the above advisements, and Patient has verbally consented to receiving psychotherapy services
from Therapist via Telehealth.
______________________________________________ ______________________________
Therapist’s Signature Date
