Teletherapy Consent Form

Teletherapy Consent Form — Form Fields

This healthcare template includes 11 fields. Obtain patient consent for remote therapy sessions including technology requirements, privacy, and limitations. Free to customize and use on ZenBuild.

• Client Name (text, required)
• Therapist Name (text, required)
• Phone Number (text, required) — For emergency contact during sessions
• Physical Location During Sessions (text, required) — 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 (multiple choice, required) — options: Yes, I understand
• I understand that teletherapy may have limitations compared to in-person sessions (multiple choice, required) — options: Yes, I understand — Including potential technology issues and limitations in crisis situations
• I understand that sessions are encrypted but no technology is 100% secure (multiple choice, required) — options: Yes, I understand
• Emergency Contact Name & Phone (text, required) — Local contact who can assist in an emergency
• Nearest Emergency Room (text, required)
• Client Signature (signature, required) — I consent to receive therapy services via telehealth
• Date (text, required)