Consent to therapy is a conversation, and the form is the record that it happened. The client should be able to read it in a few minutes, ask about anything on it, and take a copy home. A form the client signed without understanding is a signature, nothing more.
Ethics codes set out what that conversation covers. The NASW Code of Ethics (standard 1.03) lists the purpose of the services, the risks, limits that come from third‑party payers, costs, reasonable alternatives, the client's right to refuse or withdraw consent, and the time frame the consent covers (NASW). Counselors, psychologists and marriage and family therapists have their own codes with similar lists. State law and licensing boards add to them, and those rules vary by state.
This template is for consent to counseling and psychotherapy. A consent for a medical or dental procedure has a different shape, built around one procedure and its specific risks.
Which consent document do you need?
| | Where the requirement comes from |
|---|
Consent to treatment (this page) | The client agrees to therapy and understands its terms | Ethics codes, licensing boards and state law |
HIPAA consent for treatment, payment and operations | Optional permission to use records for routine purposes | Optional: 45 CFR 164.506 allows these uses without it |
| Permission to release records for a purpose that needs one | |
| Terms for sessions by video or phone | State law, boards and some payers |
| A parent's or guardian's agreement, and what the minor may agree to alone | |
For records releases, use the HIPAA consent form template or the medical release form template. For remote sessions, add the telehealth consent form template.
What each section holds
- Who you are: name, license type and number, and where the client can check it.
- The service: the type of therapy, session length, how often, and when you'll review progress together.
- Benefits and risks. Therapy often helps, and it can also stir up painful memories or feelings for a while.
- Alternatives: other approaches, group therapy, a medication evaluation, or no treatment.
- Fees, insurance and cancellations, including what the client owes if a claim is denied.
- Contact between sessions, how fast you reply, and what to do in a crisis.
- Confidentiality and its limits.
- Recording and AI note-taking, if you use either.
- Records: what you keep and how the client can ask for a copy.
- The client's right to withdraw consent and stop therapy at any time.
- Signatures and dates for the client and clinician.
Jordan is a fictional client and Sam Ortiz is a fictional counselor. Every detail is made up for illustration.
Clinician: Sam Ortiz, licensed professional counselor. License number printed on the form with a link to the state board's lookup page.
Client: Jordan, 29, they/them, starting individual counseling for work stress and trouble sleeping.
Service: Weekly 50‑minute sessions of cognitive behavioral therapy. At session 8, Sam and Jordan review progress and decide whether to continue, change approach or stop.
Risks and alternatives discussed: Talking through conflict at work may feel worse before it feels better. Alternatives offered: asking their primary care doctor about a sleep evaluation, a self‑guided CBT for insomnia workbook, or waiting. Jordan chose weekly counseling.
Fees and cancellations: Self‑pay rate and the 24‑hour cancellation policy explained. Jordan initialed both lines.
Confidentiality: Sam explained the limits that apply in the practice's state: a serious threat to Jordan's or someone else's safety, suspected abuse of a child or vulnerable adult, and a court order. Jordan asked whether their employer could find out they were in counseling. Sam's answer, also noted on the form: not without Jordan's written authorization, unless the law requires it.
Between sessions: Portal messages answered within one business day and not watched after hours. For a crisis, Jordan can call or text 988 or call 911.
AI note-taking: Sam uses a tool that drafts session notes from the audio. Jordan agreed and knows they can say no at any session.
Signed: Jordan and Sam, at the first session, after going through the form together. Jordan took a copy. Sam's intake note records that the form was reviewed and Jordan's questions answered.
Copy this into your own document. Replace the bracketed text and remove sections you don't need.
- Clinician: [name, license type and number, how to verify the license].
- Services: I agree to [individual / couples / family] therapy using [approach]. Sessions last [length] and take place [frequency]. We will review progress at [session number or date].
- Benefits and risks: [what therapy may help with; that it can be uncomfortable at times].
- Alternatives: [other options discussed, including no treatment].
- Fees and insurance: [rate, payment terms, what happens if insurance denies a claim].
- Cancellations: [notice required and any fee].
- Contact and emergencies: [how to reach you, reply time, crisis resources].
- Confidentiality and its limits: [the exceptions that apply in your state, in plain words].
- Recording and note-taking: [whether sessions are recorded or an AI tool drafts notes, and the client's choice].
- Records: [what you keep, how long, how to request a copy].
- Ending therapy: I may withdraw my consent and stop therapy at any time.
- Signatures: client [or parent or guardian, with relationship], clinician, date.
People search for one when they need the other. A consent to treatment is about care. A HIPAA authorization is about releasing information, and the Privacy Rule lists what a valid one contains (45 CFR 164.508):
- a specific description of the information to be released;
- who may release it and who may receive it;
- the purpose;
- an expiration date or event;
- the client's signature and the date;
- statements that the client may revoke it in writing, that treatment generally can't be conditioned on signing it, and that the recipient may pass the information on without HIPAA protection.
Psychotherapy notes, kept apart from the rest of the record, need an authorization for almost every release, and that authorization can only be combined with another authorization for psychotherapy notes. Keep signed authorizations for six years from the date they were created or last in effect, whichever is later (45 CFR 164.530(j)).
Writing the limits of confidentiality
HIPAA permits a provider to disclose information, in good faith, when it's needed to prevent or lessen a serious and imminent threat to someone's health or safety (45 CFR 164.512(j)). Whether you must warn or protect a third party, and what you must report about abuse, is set by state law and varies by state. Write the limits that apply where you practice in words a client can follow, and say them out loud at the first session. A citation the client can't read doesn't tell them anything.
- Starting from a surgical consent, so the form lists procedure risks and says nothing about confidentiality.
- Treating the signature as the consent. Note in the record that you went through the form and answered questions.
- Leaving out recording or AI note-taking when you use them.
- Never updating it. A new fee, a move to telehealth or a switch from individual to couples work all call for a fresh look.
- Using the treatment consent to send records to a school, employer or attorney. That release needs an authorization.
Where Twofold fits
Twofold drafts the notes that follow the consent, not the consent itself. If you go through the form in the first session and record it, the first session note can say that consent was reviewed and which questions the client asked, and you confirm that line before signing. If you use Twofold or another AI scribe, the consent should say so. See AI therapy notes for how the drafts work.
Telehealth consent form template, HIPAA consent form template, medical release form template, notice of privacy practices template and treatment plan template.
Reviewed and updated October 2026.
