Free template
Free informed consent form template
A clean, printable informed consent form template for therapy, counseling, and coaching, with prompts for each section. Free, no signup. A starting point to adapt to your practice.
Informed Consent for Services
Client name: ______________________
Date: ______________________
Practitioner: ______________________
Services and approach
Describe the services you provide, your approach, and what the client can expect from working with you.
Confidentiality and its limits
State that sessions are confidential, and the specific situations where you may be required to disclose information.
Fees and payment
State your fees, accepted payment methods, and when payment is due.
Cancellation policy
State your required notice period and any late-cancellation or no-show fee.
Consent
A statement that the client has read, understood, and agrees, with space for signature and date.
Example wording
Services and approach
Individual counseling using a cognitive behavioral approach, typically in 50-minute weekly sessions.
Confidentiality and its limits
Your information is kept private, except where I am legally or ethically required to disclose it, such as a risk of harm to yourself or others.
Fees and payment
Sessions are charged per appointment, due at the time of service, payable by card.
Cancellation policy
Please give at least 24 hours' notice to cancel or reschedule; late cancellations may be charged the full session fee.
Consent
I have read and understood the above and consent to receive services. Signature: __________ Date: __________
Want the full breakdown? Read: The client intake process
More free templates: SOAP Note · Progress Note · Client Intake Form · Treatment Plan · DAP Note · BIRP Note · Superbill · Discharge Summary
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