Informed Consent & Orientation Note (Counseling)

Encounter Details

Date/Time: [Date and time of discussion]

Clinician: [Clinician name, credentials, and supervisor if applicable]

Client: [Client name or identifier]

Encounter Modality: [in-person / video / phone]

Participants Present: [Participants present (e.g., client, guardian, interpreter, others)]

Language of Discussion: [Language used; include interpreter name/ID if applicable]

Client Location: [Client physical location] (Required for telehealth; may omit or use clinic address for in-person.)

Consent Discussion Overview

[Brief narrative summary of the consent and orientation discussion] (2–4 sentences. State whether consent was obtained at intake, re-consent due to material change, or conducted in a mandated/court-referred context. Note any capacity considerations such as guardian consent with minor assent, interpreter used, or cognitive concerns. If mandated/court-referred, identify referral source and document that reporting expectations were explained.)

Orientation to Counseling Services

[Summary of practice policies and service information reviewed] (Brief narrative or bullets noting topics covered, such as: treatment approach and scope of services, scheduling and cancellation policies, fees and billing if applicable, records access, supervision/trainee involvement if applicable, coordination of care process, and how to raise concerns. Do not reproduce policy language—simply document that topics were discussed.)

Confidentiality and Its Limits

[Statement that general confidentiality of communications and records was explained within legal and ethical limits.]

Specific limits reviewed with client:

• Imminent risk of harm to self
• Imminent risk of harm to others
• Suspected abuse or neglect of children, elders, or vulnerable adults
• Court orders, subpoenas, or other legal requirements
• Coordination of care with other providers (with appropriate authorization)
• Payer/insurance-related disclosures
• Consultation and supervision

[Statement that disclosures will be limited to minimum necessary information.]

[Special confidentiality contexts, if applicable] (Include only what applies: couples/family therapy—who is the client and policy on individual disclosures; group therapy—confidentiality among members cannot be guaranteed; minor clients—how parent/guardian access to session content is handled.)

Communication Boundaries

• [Permitted communication channels] (e.g., phone, portal, secure email, text; specify which are approved for clinical communication.)
• [Channels not used for clinical communication] (If applicable.)
• [Expected response times and availability]
• [Statement that routine messaging is not for emergencies]
• [Privacy limitations of electronic communications acknowledged]

Emergency Procedures

• [After-hours contact guidance]
• [Crisis resources provided] (e.g., 988 Suicide & Crisis Lifeline, local crisis line, emergency services)
• [Client understanding of when to activate emergency services confirmed]

Telehealth emergency details: (Include only when telehealth is used; omit for in-person-only encounters.)

• [Confirmed client physical address at time of session]
• [Local emergency resources near client location identified]
• [Emergency contact name, relationship, and phone; authorization status noted] (If pending, document plan to obtain.)
• [Technology failure plan] (Who calls whom, backup number/modality.)

Telehealth-Specific Consent

(Include this section only when telehealth services are used; omit entirely for in-person-only encounters.)

• [Client elected telehealth; understands may request in-person services when available]
• [Risks and benefits reviewed] (Privacy/security limitations, client responsibility for private space, clinical limitations of remote care, technology quality considerations.)
• [Backup modality if technology fails]
• [Identity verification method used]

Client Questions and Understanding

[Client questions and responses provided] (Brief summary of questions raised and how addressed. If no questions, note that client was given opportunity to ask and declined or had none.)

[Confirmation of understanding] (Document behavioral evidence of comprehension, such as: "Client accurately paraphrased key confidentiality limits" or "Client verbalized understanding of emergency procedures." Note any areas of confusion and clarifications provided.)

Consent and Materials Provided

Consent obtained via: [signed written consent / electronic signature / verbal consent] (If verbal, include exact statement, e.g., "Client stated: 'I understand and agree to proceed.'")

Documents reviewed/provided: [List documents, e.g., informed consent form, privacy practices notice, telehealth consent, communication policy] (Documents stored per organizational policy.)

[If consent refused or incomplete] (Document what was declined, consequences discussed, and plan—e.g., defer services, obtain guardian consent, provide referrals. Omit if full consent obtained.)