What’s Included
This digital download includes a fully customizable Telemental Health Informed Consent Template designed for mental health professionals providing virtual clinical services.
The template addresses key areas of ethical and clinical practice, including:
Introduction to Telemental Health: Definition, scope, and expectations for virtual services.
Benefits, Risks & Limitations: Technology-related risks, clinical limitations, and potential benefits.
Clinical Appropriateness: Considerations for determining whether virtual services meet a client's needs.
Privacy & Confidentiality: Client privacy, secure environments, and confidentiality limitations.
Technology & Third-Party Vendors: Electronic platforms, security, and third-party service disclosures.
Identity, Location & Jurisdiction: Client verification, physical location, and licensure considerations.
Emergency & Crisis Procedures: Emergency contacts, safety planning, and crisis response expectations.
Communication & Technology Interruptions: Electronic boundaries, response times, and connection failures.
Fees, Insurance & Cancellation Policies: Financial expectations specific to telehealth services.
Minors, Couples & Families: Additional considerations for virtual services involving multiple participants.
Client Acknowledgment & Consent: Written consent and documentation of verbal consent, where applicable.
BONUS: Optional AI Policy Statement
As artificial intelligence becomes increasingly integrated into mental health practice, clinicians need to consider how AI use is communicated to clients.
This template includes an optional, customizable AI Policy Statement addressing:
Disclosure of AI tools used in clinical or administrative services
AI-assisted documentation, transcription, and clinical support
Client privacy, data security, and third-party access
Informed consent and client choice
Human oversight and professional accountability
Customize the AI section to reflect your practice's actual technology, policies, and procedures—or remove it if it doesn't apply.
Why You'll Love This Packet
✔️ Fully editable in Google Docs (must have access to a Google/Gmail Account or create a Google Account)
✔️ Save valuable time — no need to build your telemental health informed consent from scratch.
✔️ Ethics-informed — developed with consideration of professional ethics codes and Georgia licensing board rules.
✔️ Updated for 2026 — includes contemporary technology and AI considerations.
✔️ Flexible for different clinical settings — designed for individual clinicians and group practices.
✔️ Created by a clinician for clinicians — grounded in real-world clinical practice, supervision, and ethics education.
How It Works
Download: Receive your PDF with the template access link following purchase.
Make a Copy: Open the Google Docs link and save your own editable copy to Google Drive.
Customize: Add your practice name, logo, contact information, technology policies, and applicable consent language.
Implement: Review the completed form for compliance with your professional and state requirements before incorporating it into your intake process.
Terms of Use
By purchasing this packet, you agree to the following:
You may:
Customize and brand the template for use in your own clinical practice.
Use your customized version with clients receiving services through your practice.
Save and reuse your customized form as part of your clinical intake and documentation procedures.
You may NOT:
Share, redistribute, or resell the original template.
Upload the original editable template to shared drives, websites, or platforms for others outside your practice to access.
Modify and resell the template as your own intellectual property.
Distribute the original template to other clinicians or organizations for their independent use.
By purchasing and downloading this resource, you acknowledge that the materials are examples intended for professional customization. You are solely responsible for reviewing, modifying, and implementing your own informed consent documentation.
You are encouraged to regularly review applicable laws, licensing board rules, and professional ethical standards for updates. This template is intended as an educational and professional resource to help clinicians develop their own telemental health informed consent. It is informed by professional ethical standards, including those of the ACA, NBCC, NASW, APA, AAMFT, and AMHCA, along with relevant Georgia licensing board requirements. It is not a guarantee of legal or regulatory compliance. Clinicians are responsible for adapting the template to their professional license, jurisdiction, clinical services, technology platforms, and practice policies. The template is not a substitute for legal advice or individualized compliance review.
Neither Dr. Nicole Thaxton nor Atlanta Wellness Collective, LLC assumes liability or responsibility for the use or misuse of these materials.
All original template materials are copyrighted. Unauthorized reproduction, distribution, or resale is prohibited.
Copyright © 2026 Dr. Nicole Thaxton | Atlanta Wellness Collective. All rights reserved.
Support & Custom Requests
Need help using the forms or want to request a custom bundle for your practice or training program? I’d love to hear from you!
Don’t have access to Google Docs/Gmail? You’ll need to create a Google Account to access the editable forms!
A Friendly Note from Dr. Nicole
I created this resource to help clinicians spend less time developing administrative forms and more time doing the meaningful work of caring for clients.
As a clinician, supervisor, educator, and group practice owner, I know how important it is to have thoughtful documentation that supports ethical and effective care.
If this template supports your practice, I'd be grateful if you encouraged colleagues to purchase their own copy rather than sharing the original file. Your support allows me to continue creating practical resources for our profession.
Thank you for the work you do!
Ready to Simplify Your Telemental Health Documentation?
Add to Cart and start customizing your Telemental Health Informed Consent today!