Psychotherapy Interview Consent Form

Client Information

Full Name Date of Birth Email Address

Pseudonym (if preferred)

Consent to Interview

I understand that the purpose of this psychotherapy interview is to gather information relevant to my psychological health and well-being. I have had the opportunity to ask questions about the interview process and my rights as a participant.

I understand that my participation is voluntary and that I may withdraw at any time.

Confidentiality

I understand that the information provided during the interview will be kept confidential, except as required by law. Instances where confidentiality may be broken include but are not limited to: risk of harm to self or others, or as otherwise required by legal obligation.

Contact Information (Therapist/Interviewer)

Name Contact

Additional Notes

Consent and Signature

I have read and understand the information above. I consent to participate in this psychotherapy interview.

Client Signature Date