Telehealth Informed Consent
A telehealth informed-consent form the client reads and signs before their first video visit: confidentiality and recording, fees and coverage, emergency contact, and their rights, ending in a signed acknowledgment.
Free. Updated August 2026.
What's on the form
1
Provider Information
2
Your Information
3
Emergency Contact
4
Confidentiality & Recording
5
Fees & Coverage
6
Your Rights
7
Patient Acknowledgment
8
Signatures
Who fills it in
The client, before the first video session, on paper or on screen. The provider information section is completed by the practice first, so the client sees exactly who they are consenting to see and how to reach them between sessions.
Before you hand it out
The last page of the PDF is a note to the practice, with a reminder to remove it before the packet is copied or handed out. Review the form with your clinical leadership and counsel first, and adapt anything that does not match how your practice runs.