Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Mental Health Treatment Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Therapist or Provider Name
Type of Treatment
Confidentiality Limits Acknowledged
Emergency Contact Name
Name
Relationship
Phone
Additional details
Emergency Contact Phone
Cancellation Policy Acknowledged
Consent to Treatment
Your practice's consent wording goes here.
Signature
Date
Patient Signature
Date
Date of Consent
____ / ____ / ________
Mental Health Treatment Consent Form template from formisoft.com. formisoft.com/intake-templates/mental-health-treatment-consent