The purpose of informed consent is to educate a potential patient about what to expect when in treatment with you and what to expect from your office so they may make an informed choice as to whether to become your patient. Informed consent can provide legal protection because it should describe the professional relationship and the boundaries of the treatment provided; assist with compliance with professional guidelines, state laws, and insurance requirements; and help clarify the roles and responsibilities of the psychologist and the patient.
Informed consent must be tailored to your practice, the types of patients you serve, and the services you provide. For example, an informed consent form for a psychological assessment and evaluation practice will, and should, contain different information than an informed consent form for a psychotherapy practice with adult patients.
An informed consent form for adult patients will differ from one for children that requires tailored information geared toward minors and their legal guardians/parents, the parents or guardians’ roles, and the specifics of confidentiality deserve careful additional clarification. Forensic services will involve a different informed consent process altogether, as forensic services are not considered mental health services for the purposes of treatment.
Informed consent is an ongoing process that begins with the patient’s first visit and then is routinely revisited and/or updated. The informed consent process should include verbal discussion with the patient that includes reviewing your policies and answering the patient’s questions. The patient’s informed consent should be documented by use of a written form (DOC, 33KB) that the patient will sign. That signed form should be filed in a patient’s record.
As you revisit consent, you may choose to note the update in the patient’s chart or ask the patient to sign a new form. Keeping this document updated is important as it reflects that you have notified the patient about any changes in practice policies, legal requirements, or procedures that may impact their care. Routinely review your informed consent form and make updates when significant changes in your practice, professional guidelines, or state law occur.
To ensure the information in your informed consent is understandable to the patient while also offering sufficient detail, consider splitting your informed consent document into two parts: the first part can be a detailed information sheet explaining your practice policies, procedures, and other vital aspects, and the second part can be a concise form focusing on key acknowledgements. Patients may then confirm having received and reviewed both documents by signing the shorter consent form. Consider providing a copy to your patients for their reference.
Keep your consent language clear and at an appropriate reading level for the majority of your patients. If you see patients whose primary language is not English, have your forms available in other languages. To ensure compliance with legal requirements and promote inclusivity, psychologists should check their state’s laws and regulations regarding informed consent and language access. This includes checking to see if your state requires translation into specific languages or alternative accessibility formats. For guidance on language, please consult the APA Inclusive Language Guide.
There are no national rules that specify exactly what your informed consent policy and form should include other than the principles laid out in the APA Ethics Code; however, most states have specific rules for informed consent procedures in their jurisdiction. State regulations generally outline the minimum requirements for what information must be included in an informed consent form, but the requirements and the level of detail required may vary significantly between states. Some states may have broader or more specific requirements in certain areas, such as the reporting of suicidal intent, or language requirements. Your state or territorial psychological association may be a good resource for state-specific requirements.
At a minimum, a well-designed informed consent form will address the following information:
Risks and benefits of treatment. Describe potential risks and benefits of therapy (or assessment or the specific mental health services you provide) and ensure your patients are aware that therapy may involve emotional discomfort and that side effects of specific techniques may occur. If you provide services via video or audio (telehealth), your form should address the specifics of using those modalities, including the technology required by the patient.
Fees and payment policies. Detail your fee structure, payment method, cancellation policies, and insurance claim processes. Make sure to outline not only your professional fees for your standard treatment services but also any additional fees for specific services, including legal matters or administrative work such as phone calls or requests for letters.
Include your accepted payment methods. If you accept insurance, describe the process by which you bill and how rejected claims are handled. Explain how you handle past due balances and/or use collection agencies. If you charge for cancelled appointments within a certain time frame, include that in the consent form.
The goal of this section is to ensure your patients understand all financial aspects of their services up-front, as this will help foster trust and informed decision-making and may mitigate the risk of any future misunderstandings.
Confidentiality and its limits. Explain how you keep patient information confidential, including the circumstances under which you might have to break confidentiality under your state’s laws and whether this is with or without a patient’s consent. Include legal exceptions to confidentiality, such as risk of harm to self or others, child abuse reporting, and any other situations where confidentiality may not be guaranteed. In addition, explain how and when information might be shared with third parties, such as insurance companies or legal entities.
Contact information and communication. Make recommendations on how you prefer that patients contact you, whether texting or email is acceptable, and what time frame is reasonable to expect a response from you. This section helps in setting boundaries and expectations regarding communication between you and the patient outside of your sessions.
Social media policy and general boundaries. Address your social media policy regarding “friend” requests or requests to connect online in other ways. You may want to address expectations that patients will not record sessions without your consent.
Emergency procedures. Explain how patients should contact you in mental health emergency situations and indicate whether you provide any after-hours services. Be aware that if you are a provider for insurance companies, you may be required to have some level of emergency coverage. You should review the contractual specifications with your insurer to be aware of such requirements.
Patient access to records: Explain how patients may access their treatment records, as well as any associated fees or limitations for access to their records by other health care professionals or other third parties.
Record retention. Address what kind of records you keep and for how long. It may be helpful to clarify whether a psychologist or a different entity, such as a group practice, retains ownership of a patient’s records.
Patient bill of rights and HIPAA. If your state has a patient’s bill of rights that you are required to provide, decide whether to provide it under a separate process or address it here. You are required to provide your patients with a Notice of Privacy Practices (NPP) under HIPAA. See U.S. Department of Health and Human Services. Notice of Privacy Practices. Decide whether to include your HIPAA NPP on your informed consent form or via a separate process.
Depending on the nature of your practice you may wish to also address the following in greater detail:
Please note: This document is aimed at small independent practices providing mental health services. Larger firms or institutional settings may have different needs along with the resources to obtain entity specific guidance. Additionally, this informed consent guidance is intended for voluntary therapy and is not designed to address the specifics of court-ordered treatment. The information contained in this guidance does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation.
