Free Telehealth Informed Consent Template

What is telehealth informed consent?

Telehealth informed consent is a legal document that ensures a client understands the specific risks, benefits, and limitations of receiving mental health or medical services via telephone, video conferencing, or other electronic platform rather than in person. While all clinical relationships require informed consent, telehealth adds unique considerations: technology can fail or disconnect, video quality may affect the ability to observe non-verbal cues, privacy in the client's home environment is not guaranteed, and the clinician cannot physically respond to emergencies. A telehealth-specific informed consent document educates the client about these risks and ensures they understand alternatives, confirm they have a safe and private space, verify technology requirements, explain confidentiality limits specific to telehealth, and document that the client is choosing telehealth with full knowledge of the differences from in-person care. Many state licensing boards now require telehealth-specific consent as part of responsible practice. Having a strong consent protects both the client and the provider.

What's in this template

This telehealth-specific informed consent template includes:

• Clinician & Client Information: Clinician name, credentials, license number, specialty; client name and contact information; date of consent
• Overview of Telehealth: Definition of telehealth services, description of the technology platform(s) to be used (Zoom, Doxy.me, telephone, etc.), acknowledgment that this is a real clinical relationship with the same confidentiality expectations as in-person care
• Benefits of Telehealth: Accessibility and convenience, reduced travel time, ability to access care in rural or underserved areas, continuity of care during illness or disability, flexibility in scheduling
• Risks & Limitations of Telehealth: Technology failures or connection disruptions, limitations of video in observing non-verbal communication, inability to conduct certain types of physical assessment, reduced ability to provide emergency response, potential for privacy breaches if technology is not secure, potential for inadvertent observations by others in the client's environment
• Alternatives: Client has the right to request in-person services if available, hybrid model (mix of telehealth and in-person), or referral to another provider who offers in-person care
• Technology Requirements: Equipment needed (computer, tablet, or smartphone with video capability), internet speed and stability requirements, recommended privacy settings or browser security features, what the client should test before sessions begin
• Privacy & Confidentiality Specific to Telehealth: How the clinician will protect information transmitted electronically, limitations of some platforms' privacy features, potential for third-party access if client uses employer or school-provided devices, client's responsibility to ensure a private space during sessions, encryption or security features of the platform, notice that some platforms may be subject to subpoena or discovery in legal proceedings
• Emergency Response: Client's responsibility to disclose if they are in immediate danger or crisis, understanding that telehealth clinician may not be able to provide immediate in-person emergency response, importance of the client having a backup safety plan and emergency contact numbers, instruction to call 911 if in crisis
• Recording or Retention of Sessions: Statement that sessions may not be recorded without explicit consent (unless required by law), what happens to recordings (how long they are retained, who has access), state-specific laws about recording consent
• Third-Party Access: Notification that family members or household members may inadvertently see or hear the session, client's responsibility to ensure privacy, implications for minors in the household
• Communication Between Sessions: How the clinician will be reached between sessions, response time expectations, what issues warrant a phone call vs. waiting for next session, limitations of asynchronous communication (email, messaging apps)
• Client Acknowledgments: Client confirms they have read the consent, understand the risks and benefits, have a private space for sessions, have adequate technology, understand privacy limits, consent to receive services via telehealth, understand they can request in-person alternative or discontinue at any time
• Clinician Signature & Date: Clinician signs and dates, confirming they have discussed these points with the client
• Client Signature & Date: Client signs and dates confirming understanding and informed consent

When to use this template

Use the telehealth informed consent form when:

• Beginning telehealth treatment with a new client
• Transitioning an in-person client to telehealth services
• Any mental health provider offering virtual services (therapists, counselors, psychologists, psychiatrists, nurses)
• When required by state licensing board or insurance company
• Establishing telehealth as part of treatment when in-person sessions are also provided
• Responding to complaints or regulatory inquiries about telehealth practices

This template is used across all mental health disciplines by clinicians providing any telehealth or virtual services.

How to use the template with Scriber

Review the telehealth informed consent with each new client before beginning telehealth sessions. You can record this discussion with consent and Scriber transcribes the conversation, creating documentation that you reviewed the consent and the client acknowledged understanding. This is particularly valuable if regulatory questions arise later — you have evidence of the specific discussion about privacy, technology, emergency response, and alternatives. Use the transcript to confirm key points were covered, then have the client sign the consent form. This approach documents your informed consent process and protects both the client and your practice.

Download (free)

This template is available as a printable PDF and editable DOCX file. The form includes all key elements required by most state licensing boards and standard telehealth practice guidelines. Customize it for your specific platforms (Zoom, Doxy.me, telephone, etc.), add state-specific privacy law language if needed, and use it as a standard form for all telehealth clients. Consult your state licensing board or legal advisor to ensure it meets your jurisdiction's specific requirements.

[Download PDF]

Related templates

• Release of Information Template — HIPAA-compliant form for authorizing information disclosure
• SOAP Note Template — Standard progress note format for clinical documentation