Sample Informed Consent Form


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 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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NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.