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Informed Consent for Psychotherapy Template

A printable informed consent document for psychotherapy that sets out what therapy involves, the limits of confidentiality, fees and cancellations, record-keeping, and what to do in an emergency.

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Last reviewed September 2026 · Not legal advice

Informed means understood

The document should explain the process in plain language: what sessions involve, that progress varies, and that therapy can be uncomfortable at times. It should also state the limits of confidentiality, such as risk of serious harm and legal requirements to report.

Include practicalities: fees, how cancellations work, how records are kept, and how to reach you or emergency services between sessions. Review it with the client rather than simply handing it over.

Clinic name · address · phone

Informed Consent for Psychotherapy

Client

Client name
Date

Agreement

Initial each item to confirm you have read and understood it.

InitialsI understand what therapy involves, that results are not guaranteed, and that I may stop at any time.
InitialsI understand my information is confidential, except where there is a risk of serious harm to myself or others, a duty to report, or a legal requirement to disclose.
InitialsI understand fees and cancellation terms as described by my therapist.
InitialsI understand how my records are kept and that I can request access to them.
InitialsI understand this is not an emergency service, and that in a crisis I should call 911 or a crisis line.

Signatures

Client / patient signature
Date
Practitioner name and signature
Date

Template from zdrovia.ca/templates/informed-consent-for-psychotherapy/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card requiredSee how digital forms work →

See how Zdrovia is set up for psychology practices.

Frequently asked questions

Should minors have a different consent?

Yes. Consent for minors depends on their age, capacity, and your regulator's rules.

Should I list crisis lines?

Yes. Include the local and national crisis contacts your clients can reach at any hour.

Related

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.