INFORMED CONSENT FOR THERAPY

[Practice name]
[Address, phone, and email]

Client: [Full name]
Date of birth: [Date]
Therapist: [Name, credentials, and license or registration number]

ABOUT YOUR THERAPY
Service: [Individual, couples, family, or group therapy]
Approach: [The approach your therapist uses, such as CBT, and what it involves, in one or two sentences]
Sessions: [Length, how often, and in person or by video]
How it works: The first [number] sessions are for getting to know you and your concerns. Then we agree on goals together and review them as we go. You may be asked to practice skills between sessions.

BENEFITS, RISKS, AND OTHER OPTIONS
Therapy helps many people feel better, cope with problems, and improve their relationships. Results are not guaranteed.
Talking about painful things can bring up strong feelings, and you may feel worse for a while before you feel better. Changes you make can affect the people close to you.
Other options: [Alternatives such as medication, a support group, a different kind of therapy, or no treatment]. You can ask about them at any time.

CONFIDENTIALITY AND ITS LIMITS
What you say in therapy is private. Your therapist will not share it without your written consent, except in the situations below, when the law requires or allows it:
- A serious risk that you will harm yourself or someone else
- Suspected abuse or neglect of a child or a vulnerable adult
- A court order
- [Any other exceptions that apply where you practice]
When it is safe to do so, your therapist will talk with you before sharing anything.
Consultation: [Whether your therapist discusses their work with a supervisor or colleague, without your name]

RECORDS AND RECORDING
Your therapist keeps a record of each session. It is stored [how and where] and kept for [number] years after your last session.
To see your record or get a copy: [How to ask, and how long it takes]
Recording: [Whether sessions are recorded or an AI scribe drafts the notes, what is kept, and for how long]
I agree to recording or an AI scribe: [Yes or no]

FEES AND CANCELLATIONS
Fee: [Amount per session, and the session length]
Payment: [When and how to pay, and any insurance or benefits billing]
Cancellations: [Notice needed, and the fee for a late cancellation or a missed session]
Other fees: [Letters, reports, or other work outside sessions]

CONTACTING YOUR THERAPIST
How to reach your therapist: [Phone, email, or client portal]
Replies: [Usual reply time, such as within one business day]
Messages are for scheduling and practical questions. They are not checked outside office hours.

THERAPY BY VIDEO OR PHONE
Platform: [The video platform used]
At the start of each session, your therapist will confirm where you are. Join from a private place where you can't be overheard.
Your therapist can see you only while you are somewhere they are allowed to practice. Tell them before a session if you will be away.
If the call drops: [The backup plan, such as your therapist calls you back at the number on file]
Emergency contact: [Name and phone of someone your therapist can call if they believe you are in danger]

IN AN EMERGENCY
Your therapist is not available around the clock. If you are in crisis, call or text 988. If you or someone else is in immediate danger, call 911 or go to the nearest emergency department.

CLIENTS UNDER [AGE]
Who can consent: [Who can consent to therapy for a young person where you practice]
What a parent or guardian will be told: [Such as attendance, general progress, and goals]
What stays between the young person and the therapist: [What they say in sessions, unless there is a serious safety risk]
If there is a serious risk to the young person's safety, your therapist will tell a parent or guardian, and will talk with the young person first when it is safe to do so.

YOUR RIGHTS
You can ask questions about your therapy at any time.
You can refuse any part of it, withdraw your consent, or end therapy at any time. Your therapist can suggest other services if you'd like.
Your therapist may suggest ending therapy if it is not helping, and will talk with you about other options.
If you have a concern, please raise it with your therapist first. You can also contact your therapist's regulator: [Name of the licensing or registration body, and its contact details]

CONSENT
I have read this form, or had it read to me, and my questions have been answered. I agree to start therapy with [Therapist name].
Client: [Name, signature, and date]
Parent or guardian: [Name, relationship, signature, and date, if needed]
Therapist: [Name, signature, and date]