Informed consent for psychotherapy or counseling delivered via telehealth video or audio platform, covering platform risks, confidentiality limits, crisis protocols, and ESIGN-compliant electronic authorization.
The Teletherapy / Online Therapy Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (client) and, by default, expires 30 days after it is sent if left unsigned. It covers teletherapy, telehealth, mental health. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Teletherapy / Online Therapy Consent **Provider Name:** ___________ **License Type & Number:** ___________ **Supervising Clinician (if applicable):** ___________ **Practice / Agency Name:** ___________ **State of Licensure:** ___________ --- ## Section 1 — Client Information **Full Legal Name:** ___________ **Date of Birth:** ___________ **Address (current physical location for sessions):** ___________ **City, State, ZIP:** ___________ **Phone Number:** ___________ **Email Address:** ___________ **Preferred pronouns (optional):** ___________ **Emergency Contact Name:** ___________ **Emergency Contact Phone:** ___________ **Relationship to Emergency Contact:** ___________ **Local emergency services for your current address (911 or local equivalent):** ___________ **Nearest emergency room or crisis center to your home address:** ___________ --- ## Section 2 — Nature of Teletherapy Services