Sample Informed Consent for Psychotherapy

By the APA Practice Directorate

Please Note: This is a sample informed consent document only and does not
constitute legal advice. You must ensure that your informed consent form
incorporates your own state’s laws and regulations, and we recommend that you
consult with an attorney to ensure your informed consent form complies with all
applicable laws and regulations. The information in this sample consent should not
be used as a substitute for obtaining personal legal advice and consultation.

Introduction

Welcome! This document outlines the important details regarding the psychological
services I offer in my private practice. Please read this information carefully and ask
any questions you may have before signing below. By signing this form, you
acknowledge that you have read and understood this information and that you have
had all your questions answered. If you elect to use your insurance benefits, as
described in the section below called Insurance Reimbursement, then by signing
this form you are also giving me permission to share your information with your
insurance company.
About Me
 My name is [Your Name], and I am a licensed psychologist in the state of
[Your State].
 My license number is [Your License Number].
 You can find more information about my qualifications and experience on my
website at [Your Website] (optional).
Services Offered
 I provide individual therapy for [adults (ages 18+) or children (under 18)]
experiencing a variety of challenges, including [list a few common areas you
specialize in, e.g., anxiety, depression, relationship issues].
 I utilize [list your primary therapeutic approaches, e.g., cognitive-behavioral
therapy, mindfulness-based therapies].
 I do not offer [list services you do not provide, e.g., medication management,
court-ordered evaluations].
Evaluation
 The first few sessions will involve my evaluation of your needs. This
evaluation typically lasts [insert range] sessions.
 By the end, we will discuss if I am the right therapist for you and I will offer a
treatment plan.
 I will refer you to another therapist if I believe someone else is better suited.
Psychotherapy
  Psychotherapy is a collaborative effort that requires active participation from
you.
 The approach used will vary depending on your needs and it may involve
discussing uncomfortable topics.
 There are no guarantees about the outcome of therapy, but studies have
shown psychotherapy to be helpful to those who undergo it.
Benefits and Risks of Therapy
 Therapy requires a significant investment of time, money, and energy.
Therapy can be a helpful and effective way to address emotional and
behavioral difficulties.
 Potential benefits of therapy include improved mood, reduced stress, better
coping skills, and enhanced relationships.
 However, therapy can also involve some emotional discomfort as you explore
challenging issues.
 Throughout any therapy sessions, I encourage you to ask questions. Also, feel
free to seek a second opinion at any time.
Confidentiality
 All information discussed in therapy sessions will be kept confidential, unless
you give me written permission to share such information, with some
exceptions as outlined below.
o I may be required by law to report suspected abuse or neglect, for
example regarding children, elders, or disabled adults. [Please note:
Mandatory reporting laws vary by state. In some states, not all
suspected abuse would be mandated for reporting by law. It is always
recommended that you review the relevant laws and regulations in the
state(s) you are practicing concerning your state’s specific mandatory
reporting requirements.]
o I may also be required to disclose information if compelled by a court
order.
o If I believe you may harm yourself or others, I may need to take steps
to ensure your safety or the safety of others.
o I may consult with other professionals about your case to help provide
you with appropriate care. If I do such consultations, I will make every
effort to avoid revealing information that could identify you to maintain
your privacy.
o If you use your insurance benefits, I must share clinical information
about you as described in the Insurance Reimbursement section below
at the request of your insurance company.
 If you are concerned about confidentiality in any situation, please bring it to
my attention.
Fees
 My standard fee for a therapy session is [your session fee for what length of
session].
 Sessions are typically [session duration] minutes long.
 Additional Fees:
o Additional services, including the list below, will be billed at [rate per
hour].
 Report writing
 Telephone conversations at your request
 Attendance at meetings with other professionals per your
request
 Preparation of records or treatment summaries
 Time spent performing any other service you may request of me
and to which I agree
o Tasks under one hour will be pro-rated (meaning the cost will be
calculated proportionally to the time spent on the task and not the full
hourly rate).
o Legal Matters:
 You are responsible for my professional time if legal matters
require my participation, even if I am subpoenaed.
 My fee for legal preparation and attendance at proceedings is
[rate] per hour.
Payment
 I accept payment by [list accepted payment methods].
 Payment is due at the time of service unless otherwise agreed upon.
 I do not currently accept insurance; however, I can provide you with a
detailed receipt that you may submit to your insurance company to seek
reimbursement [optional, only add if applicable].
 If you choose to use insurance, please be aware that you are responsible for
any copay, coinsurance, or deductible associated with your plan. If your
insurance denies your claim, you will be responsible for the total amount of
my fees.
 There is a [cancellation fee amount] fee for cancellations with less than
[number] days’/hours' notice.
 If your account is unpaid after [XX] days, I may use legal means, such as the
help of a collection agency, to collect payment.
Insurance Reimbursement
 Understanding your insurance coverage is important for setting realistic
treatment goals.
 I will try to help you navigate your insurance benefits and maximize
coverage, but you are ultimately responsible for payment.
 Your insurer may require authorization before providing reimbursement and
may limit the number of sessions that are covered by insurance. Should you
request more sessions beyond your insurance coverage, you would be
responsible for the total amount of those sessions.
  I recommend contacting your insurance company directly and in advance of
our first session to understand your specific mental health coverage benefits
and any limitations or pre-authorization requirements.
 Most insurance companies, including Medicare and Medicaid, require a
diagnosis to provide coverage and may request additional clinical information
(treatment plans, progress notes, etc.). When you sign this form, you are
giving me permission to share your information with your insurance company
to seek payment for your covered services.
 Choosing not to use your insurance for some or all your care. You
have the right to pay for services yourself to avoid these limitations and
potential privacy concerns associated with using your insurance.
Your Rights
 You have the right to participate actively in your treatment and make
informed decisions about your care.
 You have the right to ask questions and request clarification at any time.
 You have the right to terminate therapy at any time.
 You have the right to seek a second opinion.
 You have the right to access your treatment records, with some exceptions.
Please let me know if you would like to discuss.
Contacting Me
 When you contact my office, you are welcome to leave me a message, and I
will make every effort to return your call [time frame to return call excluding
weekends/holidays if desired].
 If you cannot reach me and require immediate help, call 911 or call 988.
 In case of an extended absence on my part, I will provide you with contact
information of a colleague who may be able to provide you with services.
My Responsibilities
 I am committed to providing you with competent and ethical psychological
care.
 I will respect your privacy and confidentiality.
 I will discuss the limitations of my expertise and refer you to another provider
if necessary.
Agreement
By signing below, you acknowledge that you have read and understood this
Informed Consent document, that you have had all your questions answered to your
satisfaction, and you consent to the releases of information described above. You
agree to participate in therapy voluntarily.
Client Signature: _________________________ Date: ______________
Psychologist Signature: _________________________ Date: ______________