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Telehealth consent printable form

Telehealth consent printable form 2026

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The document is a Telemedicine Informed Consent Form for clients engaging in teletherapy with Licensed Marriage & Family Therapist Denise J. Hockley. It outlines the nature of telemedicine, client rights, confidentiality, potential risks and benefits, and the client's right to withdraw consent at any time. The form emphasizes the importance of understanding the limitations of teletherapy compared to in-person services and includes sections for client signatures.

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Click ‘Get Form’ to open the telehealth consent printable form in the editor.
Begin by entering your name in the designated field where it states '[name of client]'. This personalizes the document and confirms your identity.
Review the section detailing your rights regarding telemedicine. Ensure you understand each point, especially your right to withdraw consent at any time.
Carefully read through the confidentiality clause. Acknowledge that while your information is protected, there are exceptions as outlined in the form.
Sign the document in the space provided for 'Signature of client/parent/guardian/conservator'. If someone else is signing on your behalf, indicate their relationship.
Finally, ensure to date the form and have your psychotherapist sign it as well, confirming mutual agreement on telehealth services.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (48 Votes)
2018	4.6 Satisfied (34 Votes)
2013	4.6 Satisfied (60 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the 5 elements of consent?

Obtaining informed consent in medicine is a process that should include describing the proposed intervention, emphasizing the patients role in decision-making, discussing alternatives to the proposed intervention, discussing the risks and benefits of the proposed intervention, and eliciting the patients preference,

What are the 5 requirements of consent?

These best practices include: Avoid jargon and overly technical language. Provide clear and specific information about the purpose of the consent form. Use a logical and intuitive layout. Explain how the data will be stored, processed and protected. Outline how users can view, modify and withdraw their consent.

How to document consent for telehealth?

Informed consent can be documented in writing or electronically before the appointment. It can also be recorded through verbal consent at the beginning of each session. If someone else is joining the visit, such as a caregiver or another provider, the additional participant must also provide consent.

What are the 5 steps of consent?

This means you and whoever you are with should be over the legal age of consent and not under the influence of drugs or alcohol and not asleep or unconscious. Consent should never be assumed it should be a clear, ongoing continuous process in every new or repeated sexual encounter.

Can I make my own consent form?

Consent must be freely given, informed, specific, unambiguous, and verifiable.

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