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Practice form example

Telepsychiatry informed consent

An illustrative outline of the topics a telepsychiatry informed-consent document commonly covers. State telehealth and licensure rules vary and change; verify current requirements.

Download the PDFPDF, 1 page, 4 KB. Free, no sign-up. For clinicians.
Educational example only. This is not legal, medical, or compliance advice, and it is not a ready-to-use legal document. Requirements vary by state, payer, and setting. Adapt anything like this to your own situation and have it reviewed by qualified legal and compliance counsel licensed in your jurisdiction before using it in a practice. You are responsible for compliance with all applicable federal and state laws, including HIPAA. shrinkiatry publishes professional commentary and education, not legal or medical advice.

Current as of July 7, 2026. Laws, payer rules, and billing codes change, so confirm the current requirements for your jurisdiction and setting before you rely on it.

What's inside

What telepsychiatry is

A plain description of care delivered by live video, what it can and cannot do, and that the clinician may recommend in-person care when appropriate.

Technology, privacy, and records

  • The platform used and its security posture, and the patient's responsibility for a private location
  • How records are kept and protected
  • That no technology is perfectly secure

Location, licensure, and coverage

  • Confirmation of the patient's physical location at each visit, which drives licensure and prescribing rules
  • That the clinician must be licensed where the patient is located

Emergencies

What to do in a crisis: call 911 or go to the nearest emergency room, and call or text 988 in the US. Telepsychiatry is not for emergencies.

Consent

  • Statement that the patient has had questions answered and consents to treatment by telehealth
  • Signature and date

About this resource

This template is part of the shrinkiatry resource library, a set of free, clinician-facing references and examples. It's reviewed by Shariq Refai, MD, MBA, FAPA, a board-certified psychiatrist, on a quarterly schedule. Next scheduled review: October 1, 2026. First published July 7, 2026, last reviewed July 7, 2026.

Browse the rest of the resource library, or verify who reviews this site. Spotted something out of date? Email corrections@shrinkiatry.com.

Educational and professional commentary only. shrinkiatry explains the profession of psychiatry. It doesn't provide medical advice, isn't a substitute for evaluation or treatment by a licensed clinician, and reading it doesn't create a doctor-patient relationship.