Teletherapy Consent Form

Obtain patient consent for remote therapy sessions including technology requirements, privacy, and limitations.

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Obtain patient consent for remote therapy sessions including technology requirements, privacy, and limitations.

Client Name

Therapist Name

Phone Number

For emergency contact during sessions

Physical Location During Sessions

City and state where you'll be located during sessions

I understand that teletherapy requires a stable internet connection, private space, and camera-enabled device

Yes, I understand

I understand that teletherapy may have limitations compared to in-person sessions

Including potential technology issues and limitations in crisis situations

Yes, I understand

I understand that sessions are encrypted but no technology is 100% secure

Yes, I understand

Emergency Contact Name & Phone

Local contact who can assist in an emergency

Nearest Emergency Room

Client Signature

I consent to receive therapy services via telehealth

By signing, you agree this constitutes an electronic signature.

Date

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