SAMPLE INFORMED CONSENT FORM

INFORMATION ABOUT THE SAMPLE PSYCHOTHERAPIST-ADULT PATIENT

CONTRACT (WITH ADDENDUM FOR CHILD/ADOLESCENT PATIENT)
Joe Scroppo, Ph.D., J.D. | Daniel O. Taube, J.D., Ph.D. | Amanda D. Zelechoski, J.D., Ph.D., ABPP

Note to clinicians: This sample psychotherapist-patient contract has been prepared for two
reasons. First, it allows you to comply with the requirement that informed consent must be
obtained from your patients (Ethical Principles of Psychologists and Code of Conduct, 2017,
Standards 10.02, 4.02). Second, it allows you to establish a potentially legally enforceable
business agreement with the patient and helps minimize the risk that business issues may become
the bases for malpractice suits and ethics or licensing board complaints. Most commentators
suggest that full informed consent is both ethically necessary and a good risk management
strategy.
This model contract is not a substitute for the HIPAA Notice of Privacy Practices or other
required HIPAA documentation. If you are a HIPAA covered entity, you must obtain a HIPAA
Notice of Privacy Practices form and give it to your clients/patients. Various organizations,
including the APA Practice Organization, have developed comprehensive HIPAA compliance
training packages, and we recommend that you seek and use such compliance packages, as well
as familiarize yourself with HIPAA and its proper implementation in your practice. The major
areas of difference between this document and HIPAA and state laws relate to: (a) patient access
to personal records, and (b) the laws and regulations governing therapeutic confidentiality,
testimonial privilege, and their exceptions.
This model form was designed for psychotherapy practices. It can and should be modified to
include other practice areas such as psychological evaluations, testing, neuropsychological
assessment, family therapy, group psychotherapy, and so on, if these are a part of your work.
There is a great diversity of business practices among psychologists. You should revise this
contract to fit your business practices rather than adjust your practices to fit the contract. Since
regulations and laws governing certain institutions are somewhat different from those governing
private practitioners, these forms may also need modification before they can be used in
hospitals, clinics, or other institutional settings.
This document includes some general language about the risks and benefits of psychotherapy, but
it should be supplemented orally or in writing by you on a case-by-case basis. This approach
was selected because the risks and benefits of therapy can vary considerably from case to case; it
is hard to design a single document that is appropriate for all situations. For example, it is
probably important to have a more thorough discussion of risks and benefits with patients who
are dealing with difficult or risky situations or issues. If you are a group or family therapist,
additional issues may need to be included. You may orally provide whatever additional
information is necessary and make a note in the record about what was said. Of course, this will
not be as protective as a signed agreement but, in most cases, it makes both clinical and risk
management sense. It is always important to remember that an informed consent contract is only

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the beginning of providing informed consent, which should be an ongoing process. Important
issues contained in this contract or not contained in this contract should be discussed when it is
anticipated that they are likely to occur and that the client may feel angry or betrayed when
they do.
You are strongly advised to have your own attorney review the informed consent document prior
to implementation. We recommend that the documentation you use be in compliance with HIPAA
and state and local statutes regulating the practice of psychology and should not include any
language that could be interpreted as a guarantee or implied warranty regarding the services
rendered.
What follows is draft text that you may feel free to adapt for your practice or agency. Sections of
the draft where you should insert numbers are designated XX, and sections you may want to add
or specially modify are [bracketed].

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 [YOUR LETTERHEAD]
OUTPATIENT SERVICES CONTRACT

Welcome to my practice. This document contains important information about my professional

services and business policies. Please read it carefully and jot down any questions you might
have so that we can discuss them at our next meeting. When you sign this document, it will
represent an agreement between us.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the
personalities of the psychologist and patient, and the particular problems you hope to address.
There are many different methods I may use to deal with those problems. Psychotherapy is not
like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the
therapy to be most successful, you will have to work on things we talk about both during our
sessions and at home.
Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant
aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger,
frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown
to have benefits for people who go through it. Therapy often leads to better relationships,
solutions to specific problems, and significant reductions in feelings of distress. But, there are no
guarantees as to what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I
will be able to offer you some first impressions of what our work will include and a treatment
plan to follow, if you decide to continue with therapy. You should evaluate this information
along with your own opinions about whether you feel comfortable working with me. At the end
of the evaluation, I will notify you if I believe that I am not the right therapist for you and, if so, I
will give you referrals to other practitioners whom I believe are better suited to help you.
Therapy involves a large commitment of time, money, and energy, so you should be very careful
about the therapist you select. If you have questions about my procedures, we should discuss
them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting
with another mental health professional for a second opinion.

MEETINGS
I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can
both decide if I am the best person to provide the services you need in order to meet your
treatment goals. If we agree to begin psychotherapy, I will usually schedule one [45-minute]
session (one appointment hour of [45] minutes duration) per week, at a time we agree on,
although some sessions may be longer or more frequent. Once an appointment hour is scheduled,
you will be expected to pay for it unless you provide XX hours [days] advance notice of
cancellation [unless we both agree that you were unable to attend due to circumstances beyond
your control]. [If it is possible, I will try to find another time to reschedule the appointment.]

PROFESSIONAL FEES

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My hourly fee is $XXX. If we meet more than the usual time, I will charge accordingly. In
addition to weekly appointments, I charge this same hourly rate for other professional services
you may need, though I will prorate the hourly cost if I work for periods of less than one hour.
Other professional services include report writing, telephone conversations lasting longer than
XX minutes, attendance at meetings with other professionals you have authorized, preparation of
treatment summaries, and the time spent performing any other service you may request of me. If
you become involved in legal proceedings that require my participation, you will be expected to
pay for any professional time I spend on your legal matter, even if the request comes from
another party. [I charge $XXX per hour for professional services I am asked or required to
perform in relation to your legal matter. I also charge a copying fee of $XXX per page for
records requests.]

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held, unless we agree otherwise or
unless you have insurance coverage that requires another arrangement. Payment schedules for
other professional services will be agreed to when such services are requested. [In circumstances
of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment
installment plan.]
If your account has not been paid for more than 60 days and arrangements for payment have not
been agreed upon, I have the option of using legal means to secure the payment. This may
involve hiring a collection agency or going through small claims court. [If such legal action is
necessary, its costs will be included in the claim.] In most collection situations, the only
information I will release regarding a patient’s treatment is his/her name, the dates, times, and
nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what
resources you have available to pay for your treatment. If you have a health insurance policy, it
will usually provide some coverage for mental health treatment. I will fill out forms and provide
you with whatever assistance I can in helping you receive the benefits to which you are entitled;
however, you (not your insurance company) are responsible for full payment of my fees. It is
very important that you find out exactly what mental health services your insurance policy
covers.
You should carefully read the section in your insurance coverage booklet that describes mental
health services. If you have questions about the coverage, call your plan administrator. Of
course, I will provide you with whatever information I can based on my experience and will be
happy to help you in understanding the information you receive from your insurance company. If
necessary, I am willing to call the insurance company on your behalf to obtain clarification.
Due to the rising costs of health care, insurance benefits have increasingly become more complex.
It is sometimes difficult to determine exactly how much mental health coverage is available.
“Managed Health Care” plans often require authorization before they provide reimbursement for
mental health services. These plans are often limited to short-term treatment approaches
designed to work out specific problems that interfere with a person’s usual level of functioning.

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It may be necessary to seek approval for more therapy after a certain number of sessions. Though
a lot can be accomplished in short-term therapy, some patients feel that they need more services
after insurance benefits end. [Some managed-care plans will not allow me to provide services to
you once your benefits end. If this is the case, I will try to assist you in finding another provider
who will help you continue your psychotherapy.]
You should also be aware that most insurance companies require that I provide them with your
clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment
plans, progress notes or summaries, or copies of the entire record (in rare cases). This
information will become part of the insurance company files. Though all insurance companies
claim to keep such information confidential, I have no control over what they do with it once it is
in their hands. In some cases, they may share the information with a national medical
information databank. I will provide you with a copy of any records I submit, if you request it.
You understand that, by using your insurance, you authorize me to release such information to
your insurance company. I will try to keep that information limited to the minimum necessary.
Once we have all of the information about your insurance coverage, we will discuss what we can
expect to accomplish with the benefits that are available and what will happen if they run out
before you feel ready to end our sessions. It is important to remember that you always have the
right to pay for my services yourself to avoid the problems described above [unless prohibited by
the insurance contract].

CONTACTING ME
I am often not immediately available by telephone. Though I am usually in my office between [9
AM and 5 PM], I probably will not answer the phone when I am with a patient. [I do have call-in
hours at XXXX on XXXXX]. When I am unavailable, my telephone is answered by an
answering service [machine, voice mail, or by my secretary] [that I monitor frequently, or who
knows where to reach me]. I will make every effort to return your call on the same day you make
it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of
some times when you will be available. [In emergencies, you can try me at my cell number.] If
you are unable to reach me and feel that you cannot wait for me to return your call, contact your
family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on
call. If I will be unavailable for an extended time, I will provide you with the name of a colleague
to contact, if necessary.
[May want to insert ELECTRONIC COMMUNICATION POLICY here; see sample policy
on https://www.trustinsurance.com/Resources/Download-Documents]

CONFIDENTIALITY [for adult patients]

In general, the privacy of all communications between a patient and a psychologist is protected
by law, and I can only release information about our work to others with your written permission.
But there are a few exceptions.
In most legal proceedings, you have the right to prevent me from providing any information
about your treatment. In some legal proceedings, a judge may order my testimony if he/she
determines that the issues demand it, and I must comply with that court order.

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There are some situations in which I am legally obligated to take action to protect others from
harm, even if I have to reveal some information about a patient’s treatment. For example, if I
believe that a child [elderly person or disabled person] is being abused or has been abused, I must
[may be required to] make a report to the appropriate state agency.
If I believe that a patient is threatening serious bodily harm to another, I am [may be] required to
take protective actions. These actions may include notifying the potential victim, contacting the
police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I
may be obligated to seek hospitalization for him/her or to contact family members or others who
can help provide protection. If a similar situation occurs in the course of our work together, I will
attempt to fully discuss it with you before taking any action.
I may occasionally find it helpful to consult other professionals about a case. During a
consultation, I make every effort to avoid revealing the identity of my patient. The consultant is
also legally bound to keep the information confidential. Ordinarily, I will not tell you about these
consultations unless I believe that it is important to our work together.
Although this written summary of exceptions to confidentiality is intended to inform you about
potential issues that could arise, it is important that we discuss any questions or concerns that you
may have at our next meeting. I will be happy to discuss these issues with you and provide
clarification when possible. However, if you need specific clarification or advice I am unable to
provide, formal legal advice may be needed, as the laws governing confidentiality are quite
complex and I am not an attorney. [If you request, I will provide you with relevant portions or
summaries of the state laws regarding these issues.]
Your signature below indicates that you have read the information in this document and agree to
abide by its terms during our professional relationship.

PATIENT SIGNATURE ________________________________ DATE _________________

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Note to clinicians: The sample language below relates to working with children and teens in
individual treatment. We recommend that clinicians meet first with parents, and then with the
children or teens (as appropriate to their developmental level). With divorced or never married
parents who cannot meet together, the professional can meet with each parent individually prior
to meeting together with parent-child dyads. This allows the clinician to clarify whether parents
have agreed to the structure proposed in the treatment contract, and will assist in the discussion
with the child or teen regarding the parameters of confidentiality, information sharing, and
records access. It also provides an opportunity for the clinician to decide, based on the parents’
responses to the contract, whether she or he will continue with the intake process and take the
child or teen on as a client. For example, if the parents refuse to agree to a teen ordinarily
having a zone of privacy, a clinician may determine that she or he is not the appropriate provider
and would refer the family and teen to another provider, rather than continuing the process of
intake and treatment.
If meeting with parents first is not feasible, or does not fit the intake procedure a clinician usually
follows, a possible alternative would be to meet at the outset with parents and children or teens
together, so as to engage in a discussion of the treatment parameters and other relevant topics
before asking the parents and children or teens to sign the consent form and/or treatment contract.

MINORS
Parent Authorization for Minor’s Mental Health Treatment
In order to authorize mental health treatment for your child, you must have either sole or joint
legal custody of your child. If you are separated or divorced from the other parent of your child,
please notify me immediately. I will ask you to provide me with a copy of the most recent
custody decree that establishes custody rights of you and the other parent or otherwise
demonstrates that you have the right to authorize treatment for your child.
If you are separated or divorced from the child’s other parent, please be aware that it is my policy
to notify the other parent that I am meeting with your child. I believe it is important that all
parents have the right to know, unless there are truly exceptional circumstances, that their child is
receiving mental health evaluation or treatment.
One risk of child therapy involves disagreement among parents and/or disagreement between
parents and the therapist regarding the child’s treatment. If such disagreements occur, I will
strive to listen carefully so that I can understand your perspectives and fully explain my
perspective. We can resolve such disagreements or we can agree to disagree, so long as this
enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will
continue. If either parent decides that therapy should end, I will honor that decision, unless there
are extraordinary circumstances. However, in most cases, I will ask that you allow me the option
of having a few closing sessions with your child to appropriately end the treatment relationship.
Individual Parent/Guardian Communications with Me
In the course of my treatment of your child, I may meet with the child’s parents/guardians either
separately or together. Please be aware, however, that, at all times, my patient is your child – not
the parents/guardians nor any siblings or other family members of the child.

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If I meet with you or other family members in the course of your child’s treatment, I will make
notes of that meeting in your child’s treatment records. Please be aware that those notes will be
available to any person or entity that has legal access to your child’s treatment record.
Mandatory Disclosures of Treatment Information
In some situations, I am required by law or by the guidelines of my profession to disclose
information, whether or not I have your or your child’s permission. I have listed some of these
situations below.
Confidentiality cannot be maintained when:
 Child patients tell me they plan to cause serious harm or death to themselves, and I
believe they have the intent and ability to carry out this threat in the very near future. I
must take steps to inform a parent or guardian or others of what the child has told me and
how serious I believe this threat to be and to try to prevent the occurrence of such harm.
 Child patients tell me they plan to cause serious harm or death to someone else, and I
believe they have the intent and ability to carry out this threat in the very near future. In
this situation, I must inform a parent or guardian or others, and I may be required to
inform the person who is the target of the threatened harm [and the police].
 Child patients are doing things that could cause serious harm to them or someone else,
even if they do not intend to harm themselves or another person. In these situations, I
will need to use my professional judgment to decide whether a parent or guardian should
be informed.
 Child patients tell me, or I otherwise learn that, it appears that a child is being neglected
or abused--physically, sexually or emotionally--or that it appears that they have been
neglected or abused in the past. In this situation, I am [may be] required by law to report
the alleged abuse to the appropriate state child-protective agency.
 I am ordered by a court to disclose information.
Disclosure of Minor’s Treatment Information to Parents
Therapy is most effective when a trusting relationship exists between the psychologist and the
patient. Privacy is especially important in earning and keeping that trust. As a result, it is
important for children to have a “zone of privacy” where children feel free to discuss personal
matters without fear that their thoughts and feelings will be immediately communicated to their
parents. This is particularly true for adolescents who are naturally developing a greater sense of
independence and autonomy.
It is my policy to provide you with general information about your child’s treatment, but NOT to
share specific information your child has disclosed to me without your child’s agreement. This
includes activities and behavior that you would not approve of — or might be upset by — but that
do not put your child at risk of serious and immediate harm. However, if your child’s risk-taking
behavior becomes more serious, then I will need to use my professional judgment to decide
whether your child is in serious and immediate danger of harm. If I feel that your child is in such
danger, I will communicate this information to you.
Example: If your child tells me that he/she has tried alcohol at a few parties, I would keep this
information confidential. If you child tells me that he/she is drinking and driving or is a

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 passenger in a car with a driver who is drunk, I would not keep this information confidential
from you. If your child tells me, or if I believe based on things I learn about your child, that
your child is addicted to drugs or alcohol, I would not keep that information confidential.
Example: If your child tells me that he/she is having voluntary, protected sex with a peer, I
would keep this information confidential. If your child tells me that, on several occasions, the
child has engaged in unprotected sex with strangers or in unsafe situations, I will not keep this
information confidential.

You can always ask me questions about the types of information I would disclose. You can ask
in the form of “hypothetical situations,” such as: “If a child told you that he or she were doing
________, would you tell the parents?”
Even when we have agreed to keep your child’s treatment information confidential from you, I
may believe that it is important for you to know about a particular situation that is going on in
your child’s life. In these situations, I will encourage your child to tell you, and I will help your
child find the best way to do so. Also, when meeting with you, I may sometimes describe your
child’s problems in general terms, without using specifics, in order to help you know how to be
more helpful to your child.
Disclosure of Minor’s Treatment Records to Parents
Although the laws of [this State] may give parents the right to see any written records I keep
about your child’s treatment, by signing this agreement, you are agreeing that your child or teen
should have a “zone of privacy” in their meetings with me, and you agree not to request access to
your child’s written treatment records.
Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody
Litigation
When a family is in conflict, particularly conflict due to parental separation or divorce, it is very
difficult for everyone, particularly for children. Although my responsibility to your child may
require my helping to address conflicts between the child’s parents, my role will be strictly
limited to providing treatment to your child. You agree that in any child custody/visitation
proceedings, neither of you will seek to subpoena my records or ask me to testify in court,
whether in person or by affidavit, or to provide letters or documentation expressing my opinion
about parental fitness or custody/visitation arrangements.
Please note that your agreement may not prevent a judge from requiring my testimony, even
though I will not do so unless legally compelled. If I am required to testify, I am ethically bound
not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court
appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide
information as needed, if appropriate releases are signed or a court order is provided, but I will
not make any recommendation about the final decision(s). Furthermore, if I am required to
appear as a witness or to otherwise perform work related to any legal matter, the party responsible
for my participation agrees to reimburse me at the rate of $XXX per hour for time spent traveling,
speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and
any other case-related costs.

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Child/Adolescent Patient:
By signing below, you show that you have read and understood the policies described above. If
you have any questions as we progress with therapy, you can ask me at any time.

Minor’s Signature* _______________________________________ Date___________________

Parent/Guardian of Minor Patient:

Please initial after each line and sign below, indicating your agreement to respect your child’s
privacy:
I will refrain from requesting detailed information about individual therapy sessions with my
child. I understand that I will be provided with periodic updates about general progress, and/or
may be asked to participate in therapy sessions as needed. ________ ________
Although I may have the legal right to request written records/session notes since my child is a
minor, I agree NOT to request these records in order to respect the confidentiality of my
child’s/adolescent’s treatment. ________ ________
I understand that I will be informed about situations that could endanger my child. I know this
decision to breach confidentiality in these circumstances is up to the therapist’s professional
judgment, unless otherwise noted above. ________ ________

Parent/Guardian Signature ________________________________________ Date__________

Parent/Guardian Signature ________________________________________ Date__________

* For very young children, the child’s signature is not necessary

Thanks to Sherry Kraft, Ph.D., clinical psychologist for The Center for Ethical Practice, for use of some the
examples and concepts in the child/adolescent portion of this template informed consent.
http://www.centerforethicalpractice.org

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