Telemental Health Consent Form Template

Client Name: ______________________________                File Number/Code:______

Date: ______________

I,_____________________________________(client), hereby consent to engage in telemental health services with _______________________________________(practitioner).

 I understand that “telemental health services” may include a wide range of online interactions with the mental health practitioner over different online platforms. I understand that the mental health practitioner will only use digital platforms that meet the legal requirements of telehealth services.

I understand that I have the following rights and responsibilities regarding telemental health services

1. I enter this treatment voluntarily and am able to withdraw from the process at any time, provided I have met all contractual requirements.

2. Confidentiality as described in the Contract of Services remains intact during telemental health services—both the keeping of confidentiality and the limitations of confidentiality.

 3. I acknowledge that there are risks, including, the possibility, despite all efforts made by the practitioner, that: the transmission, storage, and access to digitally stored information may be accessed by unauthorized persons.

4. I acknowledge that telemental health services do not allow for emergency intervention, therefore, I will develop an emergency intervention plan with my practitioner to ensure my safety at all times.

5. I am responsible for my own technical requirements, including access to internet services, privacy, etc.

6. I acknowledge that I cannot record any of these consultations on my own device.

 I have read, understand, and agree to the information provided above.

___________________

Client

In the event of the client being a minor, the therapist requires both parents to consent to treatment/therapy/assessment before moving forward with the first consultation.

________________________                  ________________________

Parent 1 Signature                                   Parent 1 Name

________________________                  ________________________

Parent 2 Signature                                   Parent 2 Name

DATED at ________________ on this ______ day of _________________

References:

Telehealth HHS. (2023). Obtaining Informed Consent. https://telehealth.hhs.gov/providers/preparing-patients-for-telehealth/obtaining-informed-consent

You can download more Mental Health worksheets here.

Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.