How to Create a Telehealth Therapy Consent Form for Telehealth Therapy Practices (with Free Template)
This guide walks a telehealth therapy practice through the ten substantive steps of building a state-aware telehealth consent. The result is a delivery-ready form covering home-state licensure and compact participation (PSYPACT for psychologists, the Counseling Compact for LPCs, the Social Work Licensure Compact for LCSWs), the APA Guidelines for the Practice of Telepsychology, the patient-state acknowledgment block, the emergency-contact requirement, the technology-limitation disclosure, the HIPAA- aligned video platform and Business Associate Agreement reference under 45 CFR 164.314, the mandatory-reporting framework keyed to the state of patient physical location, the e-signature audit trail under ESIGN, and the recurring patient-state check-in workflow. Each step is one paragraph of working guidance. Estimated time end-to-end: 45 minutes from blank document to signed PDF using an AI form builder. Formfy is the AI form builder telehealth therapy practices use to ship state-aware telehealth consent in one workflow.
Before you start, gather six pieces of information: (1) the practitioner home-state license, NPI, and any compact credential (E.Passport, Privilege to Practice), (2) the list of states the practice serves and the licensure pathway in each (direct license, compact privilege, telehealth registration), (3) the HIPAA-aligned video platform name and BAA execution date, (4) the e-signature platform name and BAA execution date, (5) the practice emergency protocol (988, local crisis line, mobile crisis team, nearest emergency department), and (6) any state-specific telehealth statute the practice must reference (e.g., Texas Occupations Code 111.005, California Business and Professions Code 2290.5). With those six inputs, the substantive drafting takes under 45 minutes.
Step 1: Confirm home-state license and compact participation
The first step is to confirm the practitioner home-state license and any interstate compact participation. The state where the patient is physically located at the time of the encounter controls licensure, and the consent form must accurately disclose the practitioner credential. For licensed psychologists, PSYPACT (the Psychology Interjurisdictional Compact) provides telepsychology authority across PSYPACT member states under the E.Passport mechanism issued by the Association of State and Provincial Psychology Boards. For Licensed Professional Counselors and equivalent titles (LPCC, LMHC), the Counseling Compact (operational 2024) provides a Privilege to Practice across compact member states. For Licensed Clinical Social Workers, the Social Work Licensure Compact entered implementation in 2024. Confirm active state membership lists on each compact website (psypact.org, counselingcompact.org, swcompact.org) before drafting.
Step 2: Reference APA Guidelines for the Practice of Telepsychology (or ACA telebehavioral guidelines)
The APA Guidelines for the Practice of Telepsychology (originally 2013, with continuing revisions) cover competence, professional standards of care, informed consent, confidentiality, security, data disposal, testing and assessment, and interjurisdictional practice. Guideline 3 specifies that informed consent for telepsychology must address the technology used, the security and confidentiality limits of the technology, the emergency-contact protocol, and the licensure framework. For LPCs, the American Counseling Association telebehavioral health guidelines and the National Board for Certified Counselors (NBCC) standards parallel the APA structure. For LCSWs, the National Association of Social Workers (NASW) Standards for Technology and Social Work Practice cover similar ground. Reference the relevant professional-association guideline in the consent form to anchor the standard of care.
Step 3: Add the patient-state acknowledgment block
A patient-state acknowledgment block is the load-bearing element of the telehealth consent. It typically includes four affirmations. First, the patient confirms physical location at the time of each encounter. Second, the patient confirms understanding that the practitioner is licensed in (or holds a compact privilege to practice in) the patient state. Third, the patient agrees to notify the practitioner before any change in state of physical location. Fourth, the patient acknowledges that if the practitioner is not licensed (or compact-credentialed) in a new state, services may need to be terminated with referral. Best practice is a checkbox plus a free-text confirmation of current state of physical location, captured each session via the intake form or scheduling tool. Document each affirmation in the audit trail.
Step 4: Disclose the emergency-contact requirement and crisis protocol
Emergency-contact requirement is a baseline element of every state-specific telehealth consent. The patient must designate at least one local emergency contact (name, relationship, phone number) at intake. The consent should disclose the practitioner protocol for crisis events: contact 911, contact the local crisis hotline (988 Suicide and Crisis Lifeline as the federal default), contact the local mobile crisis team where available, contact the local emergency department. The consent should disclose the patient nearest emergency department (often captured at intake). The protocol should address connection-loss events: how the practitioner will attempt to re-establish contact, when the practitioner will contact the emergency contact, when the practitioner will notify local emergency services. Document the emergency protocol in the chart record.
Step 5: Add the technology-limitation disclosure
A technology-limitation disclosure documents the patient understanding that telehealth has inherent limits: video and audio quality may vary, connection may drop, certain assessments (acute suicide risk, formal cognitive testing, observation requiring physical presence) may be more limited via telehealth, and the practitioner may recommend an in-person visit or emergency referral if telehealth is clinically inadequate. The clause should not waive any liability for clinician negligence (waivers of clinician negligence are generally unenforceable in malpractice contexts). Plain-language disclosure of the limits and the practitioner protocol for converting to in-person or emergency referral is the standard. The consent should also include a no-recording, no-screen-recording provision because session recordings are protected health information and unauthorized recordings violate confidentiality.
Step 6: Identify the HIPAA-aligned video platform and BAA status
The video platform must be configured for HIPAA-aligned operation, and the vendor must execute a Business Associate Agreement (BAA) under 45 CFR 164.314(a) and 45 CFR 164.504(e). Common HIPAA-aligned video options used by therapy practices: Zoom for Healthcare, Doxy.me, SimplePractice Telehealth, TheraNest Telehealth, Microsoft Teams (with HIPAA configuration), Google Meet (with Google Workspace BAA). The free consumer versions of these platforms typically do not include a BAA; the consumer Zoom and Google Meet are not BAA-covered. The consent form should name the platform, disclose the BAA status, and confirm that protected health information transmitted through the platform is covered by the BAA. Document the BAA execution date and renewal cadence in the practice compliance binder.
Step 7: Reference state telehealth parity and reimbursement framework
Telehealth parity is a separate concern from licensure and consent, but the consent form may reference it for transparency. Parity statutes require commercial health plans to cover telehealth-delivered behavioral health services on the same basis as in-person services. Coverage parity requires the plan to cover the service via telehealth but may pay differently. Payment parity requires the plan to pay the same rate for telehealth as for in-person. A growing number of states require both. Federal law under the Bipartisan Budget Act of 2018 and subsequent appropriations bills expanded Medicare telehealth flexibility for behavioral health, with provisions extended through additional appropriations bills. The consent does not need to disclose parity rules but the practice should verify reimbursement before scheduling and disclose any patient out-of-pocket cost.
Step 8: Add mandatory reporting and Tarasoff disclosure for the relevant state
Mandatory reporting follows the state where the patient is physically located at the time of the disclosure. If a clinician licensed in California provides telehealth to a patient physically in Texas, the clinician follows Texas Family Code 261.101 mandatory reporting timelines and reporting agencies, not California. Most states extend mandatory reporting to suspected abuse of children and vulnerable adults. The Tarasoff duty to warn or protect identified third parties applies similarly under the law of the state of patient location. The consent form should disclose this multi-state framework and identify the practitioner protocol for navigating the patient state mandatory-reporting rules. Practitioners providing telehealth across state lines must maintain working knowledge of mandatory-reporting rules in each patient state.
Step 9: Confirm e-signature workflow and audit trail
The federal Electronic Signatures in Global and National Commerce Act (ESIGN Act) at 15 U.S.C. 7001 and the Uniform Electronic Transactions Act (UETA), adopted in 49 states, give electronic signatures the same legal effect as wet-ink signatures for nearly all consumer and professional services contracts. Telehealth informed consent is squarely covered. Use an e-signature workflow that produces a tamper-evident audit trail with timestamp, IP address, and consent-to-electronic-records affirmation. The platform must be HIPAA-compliant and operate under a Business Associate Agreement under 45 CFR 164.314 because the consent contains protected health information. Formfy, SimplePractice, TherapyNotes, DocuSign, and Adobe Acrobat Sign all sign HIPAA BAAs. Store the signed packet (informed consent, telehealth consent addendum, patient-state acknowledgment) so it can be retrieved on 24-hour notice for licensing-board or audit requests.
Step 10: Build the recurring patient-state check-in into the workflow
Initial telehealth consent is captured once, but the patient-state acknowledgment must be re-affirmed at each encounter. Build the recurring check-in into the scheduling or intake workflow: a one-line confirmation that the patient is physically in the same state disclosed at the previous session, plus a checkbox affirming a private and confidential location. If the patient state has changed, the workflow should route to either an updated consent (if the new state is covered by the practitioner license or compact) or a clinically appropriate referral protocol (if the new state is not covered). The consent itself should specify a renewal cadence (commonly annual or per significant change in licensure or platform). Document each recurring affirmation in the audit trail.
Free template and downloadable PDF
Formfy ships a telehealth therapy consent template that maps one-to-one to the ten steps in this guide. The template is editable in the AI form builder: describe the home state, the compact participation, the video platform, and the emergency protocol and the builder returns a delivery-ready packet with the patient-state acknowledgment, technology-limitation disclosure, emergency-contact block, HIPAA video BAA reference, mandatory-reporting language, and the e-signature block.
See also: /faq/telehealth-therapy-practices-telehealth-consent for the FAQ companion hub covering 17 of the most common telehealth therapy consent questions.
Related resources
Build a telehealth therapy consent in 45 seconds
Free 15-day Formfy trial. No credit card. Submission-based pricing.
Start your free trialLast verified: 2026-04-25. This page is informational; it is not legal or clinical advice. Telehealth therapy practices should review state-specific telehealth statutes, current compact membership lists, and patient-state acknowledgment rules with counsel and the relevant licensing board.