Free PDF template
Therapy Consent Form
Therapy Consent Form — a 8-page PDF form with 19 fill-in fields and sections covering psychological services, meetings, professional fees and 11 more sections.
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How to fill out the Therapy Consent Form
Work through the form section by section in your browser, then download the completed PDF.
- Psychological Services
- Meetings
- Professional Fees
- Billing And Payments
- Insurance Reimbursement
- Contacting Me
- Confidentiality (adult Patients)
- Signature
- Authorization
- Parent/guardian Communication
- Mandatory Disclosure Of Treatment Information
- Disclosure Of Minor’s Treatment
- Disclosure Of Minor’s Treatment To Parents
- Signatures
Information you will need
- What time is the therapist usually first in the office?
- What time does the therapist usually leave the office?
- What time does the therapist have call in hours?
- What days does the therapist have call in hours?
- How many minutes is the average weekly session?
- How many hours' notice should the patient give to cancel their session without penalty?
- What’s the therapist's hourly fee?
- How many minutes of a telephone conversation will count as a professional service?
- What’s the therapist's rate for professional services in a legal matter?
- What’s the therapist's rate per page for record requests?
- How many days must the patient’s account be past due before the therapist will execute legal action?
- What state does the therapist practice in?
- What’s the therapist's hourly rate to perform work for legal matters?
- What's the patient's full name?
- What's the minor patient's full name?
- What's the parent/legal guardian's full name?
- What's the second parent/legal guardian's full name?
- How many sessions is the minimum for a patient evaluation?
- How many sessions is the maximum for a patient evaluation?
The form includes 3 signature lines, a witness section.
PDF facts
- Format
- File size
- 848 KB
- Pages
- 8
- Version
- 1
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