Mental Health Therapy Informed Consent Form

Client Information

Full Name: Date of Birth: Phone Number: Email Address:

Therapist Information

Therapist Name: Contact Information:

Nature, Purpose, and Risks of Therapy

Confidentiality & Its Limits

Consent

• I understand the nature and anticipated course of therapy.
• I understand the limits of confidentiality.
• I understand that participation is voluntary and I may withdraw at any time.
• I have had the opportunity to ask questions and receive answers.

Client Consent & Signature

Client Signature: Date: