free tool
Therapy consent form generator
Fill in your practice details and pick what applies to you. The form below updates as you go, written for Indian practice: the confidentiality exceptions in the Mental Healthcare Act, POCSO reporting, the NIMHANS items for online sessions, and separate terms for minors and couples. Edit the wording, then print it or download a PDF. It all runs in your browser, so nothing you type is sent to us.
This is a template.It is general information, not legal advice. Adapt it to your practice and have a lawyer check your final form, especially the confidentiality clauses, and check your own professional body's code.
CONSENT TO THERAPY
Please read this before our first session and bring any questions. We will go over the main points together. You can withdraw your consent at any time.
1. About me
Therapist: ____________________________
Qualifications and registration (RCI or NCAHP number if you hold one): ____________________________
2. What therapy involves
Therapy is something we do together. We will meet in person or online, for sessions of 50 minutes, and we will review how it is going from time to time. Therapy often brings relief, and it can also feel harder before it feels better. I can't promise a particular result. You can ask me about my approach at any point, say no to any exercise I suggest, or stop therapy whenever you choose.
3. Fees and cancellations
Fee: ________________ for a session of 50 minutes.
How to pay: UPI after each session.
If you need to cancel, please tell me at least 24 hours before the session. Sessions cancelled later than that, or missed, may be charged as set out here: ________________.
I will tell you at least ________________ in advance before my fee changes. If unpaid fees build up, I will raise it with you, and we may pause sessions until we have agreed how they will be paid.
4. Confidentiality and its limits
What you tell me stays between us, with a few exceptions. I may need to share information if I believe you or someone else is at serious risk of harm, if I learn that a child has been or may be sexually abused (the law requires me to report this), or if a court or other legal authority orders me to.
In more detail, the Mental Healthcare Act, 2017 (section 23) allows information to be released:
• to your nominated representative, so they can carry out their role under the Act;
• to other mental health and health professionals, so they can provide care;
• if it is necessary to protect another person from harm or violence, or to prevent a threat to life, and then only as much as is needed;
• on the order of a Mental Health Review Board, the Central Authority, a High Court, the Supreme Court or another competent statutory authority;
• in the interests of public safety and security.
Under the POCSO Act, 2012, anyone who knows or suspects that a sexual offence against a child (anyone under 18) has happened, or is likely to, must report it to the police. This applies even if you ask me not to report, and it covers what you tell me about a child you know, not only about yourself. It includes sexual activity involving anyone under 18, even if the young people involved describe it as consensual.
I discuss my work in supervision without your name or identifying details.
Wherever I can, I will talk to you before sharing anything.
5. Records and your data
I keep notes of our sessions and the details you give me, such as your contact information. You can ask to see your records. I may hold back a specific part only if seeing it would seriously harm you or put someone else at risk, and I will tell you if I do.
Where I keep them, and who can see them: ________________
What I use your data for: arranging and providing your therapy, billing, and keeping the records my profession expects. I collect only what that needs. You can withdraw your consent at any time by telling me, which is as easy as giving it; I may still need to keep some records where the law requires it. You can also ask to correct your details. If you are unhappy with how I handle your data, tell me first. You can also complain to the Data Protection Board of India.
I take reasonable care to keep your information secure, but no system is completely safe from a breach.
6. Contact between sessions
How to reach me: Phone or WhatsApp, for appointments only. I usually reply within one working day.
I am not an emergency service. In an emergency, call 112. Tele-MANAS, the free government mental health helpline, is on 14416 or 1-800-891-4416.
7. Your emergency contact
Someone I can contact only if I am seriously worried about your safety and can't reach you. I won't contact them for any other reason without asking you first.
Name: ____________________________
Relationship to you: ____________________________
Phone number: ____________________________
8. Online sessions
Platform: ________________
• At the start of therapy I will check your age and identity with a government ID shown on camera, and I will confirm it is you at the start of each session.
• I will ask where you are at the start of every session, because emergency help needs an address.
• Please join from a private place where you can speak freely. I will do the same.
• Neither of us will record a session or share what is said in it by email, messaging apps or social media.
• If the connection fails, I will try to call you by phone. If that does not work, we will end the session and reschedule.
• Online sessions are by appointment and are not suitable for emergencies. If online work is not enough, I will recommend in-person or emergency care.
Your current address: ____________________________
Nearest hospital to where you usually join from: ____________________________
9. Recording
I do not record sessions, and I ask you not to record them either.
10. Ending therapy
You can stop therapy at any time. If I think we should pause, change format or that someone else could help you better, I will explain why and recommend what to do next. I will tell you about planned breaks in advance.
If I suddenly became unable to work, ________________ would contact you to let you know and help you find continued care.
11. Agreement
Please tick each statement you agree with (tick all that apply)
☐ I have read this form, or had it explained to me in a language I understand, and I have had the chance to ask questions.
☐ I understand what therapy involves and that I can stop at any time.
☐ I understand the limits of confidentiality described above.
☐ I agree to the fees and cancellation terms.
☐ I agree to the arrangements for online sessions.
☐ I consent to my personal data being used as described above.
Client signature: ____________________________ Date: ______________
Therapist signature: ____________________________ Date: ______________
Form version (date): ____________________________
Go through it with the client
A signed form shows you had the conversation. It doesn't replace it. Send the form before the first session, then spend five minutes at the start of that session on the parts people skim: confidentiality limits, contact between sessions and what happens in an emergency. Give the client a copy, date each version of your form, and ask again when the terms change, for example when you move to online sessions, a family member joins, or your fee changes.
What the form leaves out
There is no clause asking the client not to hold you responsible for adverse events or data breaches. Some sample forms include one, but a clause that tries to excuse your own carelessness is unlikely to protect you in India: the Indian Contract Act voids agreements opposed to public policy, consumer commissions can strike out unfair contract terms, and your duty under the DPDP Act to keep client data secure can't be signed away. The form says instead what you can and can't control. If you still want a liability clause, have a lawyer draft it.
Every clause follows our guide to informed consent forms, which explains each one with its source. If you'd rather start from a fixed document, there is also an informed consent template. The consent form and the intake form do different jobs; build the second with the intake form builder.
More free tools: the invoice generator and the fee calculator. If you or a client needs urgent help, call 112 or Tele-MANAS on 14416.
Get it signed online: try Therapy Manager free
In Therapy Manager, the agreement template in Forms can be sent to a client before the first session and signed online, and the signed copy stays with their record.
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