Establishing secure connection…Loading editor…Preparing document…

MFT Informed Consent Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Informed Consent: Disclosure Statement & Agreement for Services

Kristy Kirby, MFT #48653

(for your records)

Introduction

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask any questions you may have regarding its contents.

Information about your Therapist

I am a licensed Marriage and Family Therapist. I believe that therapy should be tailored to each individual’s needs. I use various therapeutic modalities including Cognitive Behavioral Therapy (CBT), Solution Focused Therapy, Multi-Generational Therapy, Structural Therapy, Client Centered/Play Therapy and Family Therapy. I have found that using multiple interventions and structures helps to provide what is necessary to make positive and lasting changes. I have experience in numerous settings working with children through teenagers, adults and the older adult population.

If you have further questions about my background, experience and professional orientation, please let me know.

Fees & Insurance

Individual therapy sessions are $95.00 per 50-minute session.

Couples sessions are $95.00 per 50-minute session.

Family sessions are $125.00 per 75-minute session.

I currently accept cash or checks which will be due prior to session start. You may also pay by credit card/debit card through my website at www.kristykirby.com and click on the Payment tab. Please pay prior to session start. If a charge or a check is not honored by your bank, please be aware that any additional charges for the returned items will be your responsibility.

Services may be covered in full or in part by your health insurance or employee benefit plan. I will provide a receipt for services that you can submit to your insurance company for reimbursement. Please check with your insurance company to determine your benefits and reimbursement rates as this will vary.

If you are using insurance or an EAP, please check to make sure that I am authorized to bill on your behalf. You will need to fill out an Authorization to Release Information form so that I may speak with the insurance company regarding your sessions. Please note that if you are using a third party, some information will not be confidential such as diagnosis and treatment issues. If you have questions about this please let me know.

If for some reason you find that you are unable to continue paying for your therapy, please let me know. We can discuss the options available to you including possible reduced rates for services or referrals for low income services.

Confidentiality & Privacy Policy

All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release. However, it is important that you know that I utilize a “no-secrets” policy when conducting family or marital/couples counseling.

There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child abuse, elder abuse or dependent adult abuse. Therapists may be required or permitted to break confidentiality when they have determined that a client presents a serious danger of physical violence to another person or when a client is dangerous to him or herself. In addition, a federal law know as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the client that the FBI sought or obtained the items under the Act. Please ask about any questions you have regarding confidentiality and exceptions to confidentiality.

Minors and Confidentiality

Communications between therapists and clients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, in the exercise of my professional judgment, I may discuss the treatment progress of a minor patient with the parent or caretaker. Clients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic.

Appointment Scheduling and Cancellation Policies

Sessions are typically scheduled to occur one time per week at the same time and day if possible. I may suggest more or less therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify me at least 24 hours in advance of your appointment time. Please contact me at 707-365-9246. If you do not notify me with at least 24 hours of the cancellation, you will be responsible for a $55.00 cancellation fee. Please understand that you insurance company will not reimburse you for missed or cancelled sessions. A Credit Card Release, or undated check, will be required to keep on file after the first missed appointment.

Therapist Availability/Emergencies

Telephone consultations between office visits are welcome. However, I will attempt to keep those contacts brief due to my belief that important issues are better addressed within regularly scheduled sessions. You may leave a message for me at any time on my confidential voicemail. Please be sure to leave your name and phone number(s) along with a brief message concerning the nature of your call. Non urgent phone calls are returned during normal workdays within 24 hours. If you have an urgent need, please indicate that fact in your message and follow instructions that are provided in my voicemail message.

In the event of a psychiatric emergency or an emergency involving a threat to your safety or the safety of others, please contact Solano County Crisis at 784-1131, or call 911.

Therapist Communications:

I may need to communicate with you by telephone, mail, or other means. Please indicate your preference by checking one of the choices listed below. Please be sure to inform your therapist if you do not wish to be contacted at a particular time or place, or by a particular means.

About the Therapy Process

It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to me and the specifics of your situation, I will provide recommendations to you regarding your treatment. I believe that therapists and clients are partners in the therapeutic process. You have the right to agree or disagree with my recommendations. I will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion.

Due to the varying nature and severity of problems and the individuality of each client, I am unable to predict the length of your therapy or to guarantee a specific outcome or result.

Termination of Therapy

The length of your treatment and the timing of the eventual termination of your treatment will depend on the specifics of your treatment plan and the progress you achieve. Planning your termination is something we will do in collaboration.

You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either you or I may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating therapy.

This is your copy; please read it carefully before signing.

Your signature indicates that you have read this agreement for services and understand its contents.

Please ask any questions or discuss concerns you may have about this information before you sign.

Signature

Date

Signature (if more than one client)

Date

I have read and understand the Informed Consent: Disclosure Statement & Agreement for Services.

I further understand that I am responsible for services even if my insurance does not cover the cost. I understand that I will be charged a $45.00 cancellation/no show fee for appointments not cancelled within 24 hours by phone, email, or text and that I may be required to keep a Credit Card Agreement on file to cover these costs.

I also have read about the Privacy Policies and Confidentiality and understand that my therapist is a mandated reported and certain information, by law, may be reported.

I also have been notified in this informed consent of whom to contact in case of a psychiatric emergency.

I know that it is my responsibility to contact my therapist for further clarification, questions or concerns regarding this document.

Primary Client Name

Signature

Relationship to Client if client is a minor

Date

Client Name (If more than one client)

Signature

Relationship to Client

Date

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the MFT Informed Consent Form Is

The MFT Informed Consent Form is a written record that documents a client’s agreement to begin psychotherapy with a licensed Marriage and Family Therapist. It explains the scope of services, confidentiality limits, telehealth options, fees and payment terms, emergency procedures, and the client’s rights. The form helps establish mutual expectations, documents consent for treatment and recordkeeping, and creates a baseline for later administrative or clinical decisions if disputes or legal questions arise.

Why a Clear Consent Form Matters

A thorough MFT Informed Consent Form reduces clinical and legal risk by documenting client understanding and agreement, clarifying confidentiality boundaries, and recording consent for telehealth or third-party disclosures under applicable federal law such as ESIGN and HIPAA.

Why a Clear Consent Form Matters

Who Completes and Signs This Form

Summary: Ensure signatures and dates are present and that any required guardian or substitute decision-maker is documented on the same form.

  • Licensed MFT or Clinician — Prepares form, explains terms, documents informed consent before treatment begins.
  • Adult Client — Reviews, initials applicable sections, and signs to confirm voluntary consent for treatment.
  • Parent or Legal Guardian — Signs when client is a minor or lacks decision-making capacity.

Typical Signers and Roles

Licensed MFT

The treating therapist signs to confirm disclosure of treatment methods, fees, confidentiality limits, and emergency procedures. Their signature documents who provided the information and establishes a record for clinical and supervisory review.

Client / Guardian

The client or authorized guardian signs to indicate understanding and voluntary agreement to services. For minors or incapacitated adults, the guardian’s signature establishes authority and clarifies decision-making responsibilities.

Security, Privacy, and Compliance Basics

HIPAA: Protects PHI; BAA required for vendors
Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Access Controls: Role-based access and user authentication
Audit Trail: Timestamps, IP, signer actions retained
Retention: Keep signed records per policy
BAA Requirement: Execute Business Associate Agreement when needed

Step-by-Step: Completing the MFT Informed Consent Form

Follow this sequence to reduce errors and ensure valid consent before treatment begins.

  • 01
    Prepare the Form: Confirm client identity and prefill known fields.
  • 02
    Explain Terms: Review confidentiality, limits, fees, and telehealth.
  • 03
    Collect Signatures: Obtain client and clinician signatures, date each.
  • 04
    Store Securely: Save to encrypted client record with audit trail.

Routing and Submission Workflow

The form typically travels from clinician to client and back; recordkeeping and payer copies follow as needed.

  • Create Document: Upload template to your records system.
  • Send to Client: Deliver via secure e-sign or in-person.
  • Receive Signed Copy: Capture audit trail and store copy.
  • Archive: Retain per retention schedule and HIPAA.

Technical Delivery Options and Integrations

Verify vendor compliance (BAA available), encryption standards, and record export options before eSignature use in clinical workflows.

  • File Formats: PDF, DOCX, HTML
  • Integrations: EMR, Google Workspace, Microsoft 365
  • Authentication: Email, SMS code, or stronger methods

Timing and When to Obtain Consent

Obtain and document informed consent before providing treatment, and update records when material changes occur.

Before First Session:

Consent must be signed and dated prior to or at intake.

Prior to Telehealth:

Document explicit telehealth consent for remote sessions.

When Terms Change:

Re-obtain consent if fees or treatment scope change.

Annual Review:

Consider reviewing consent at least yearly for ongoing care.

Upon Transfer:

Update consent when care transfers to another clinician.

Common Preparation Mistakes to Avoid

  • Using incomplete or unsigned forms that leave key sections blank, such as emergency contact or telehealth consent.
  • Recording inconsistent names or dates that complicate insurance billing or legal verification later on.
  • Failing to execute a BAA with third-party eSignature vendors when PHI is processed.
  • Relying on weak authentication for remote signatures without documenting consent or signer identity.

Risks and Regulatory Consequences

HIPAA Penalties: Civil fines and corrective action
Malpractice Liability: Claims if consent is inadequate
License Sanctions: State board discipline possible
Insurance Denial: Claims declined for missing consent
Invalid Consent: Treatment authorization may be void
Data Breach Costs: Notification and remediation expenses

Realistic Use Cases for MFT Consent Forms

Two common scenarios illustrate how the MFT Informed Consent Form is used in practice.

Private Practice Intake

A therapist sends the consent form before the first visit to collect signatures and telehealth consent.

  • The client signs electronically via a secure platform.
  • The signed record is saved in the practice management system with an audit trail and a PDF copy attached to the client chart for continuity of care and billing verification.

Community Clinic Workflow

A clinic uses a standardized consent template for all new clients to ensure consistent disclosures.

  • Staff review and witness signatures in person when required.
  • The clinic archives signed forms centrally, enforces role-based access, and schedules annual reviews to confirm ongoing consent.

Customizing an Online Consent Workflow

Common configuration settings help adapt the consent form to your practice and meet compliance needs.

Field Configuration
Template Selection Choose a master consent template
Conditional Fields Show telehealth options when selected
Signer Authentication Enable email, SMS, or KBA
Auto-Archive Save signed PDF to client record

How MFT Informed Consent Differs from a HIPAA Authorization

Use this quick comparison to distinguish treatment consent from authorization to release protected health information.

Feature MFT Consent HIPAA Authorization
Primary Purpose consent to treatment permit phi disclosure
Scope clinical services specific recipients and uses
Revocation can withdraw consent can revoke authorization
Required Elements treatment terms names, purpose, expiration

eSignature Vendor Pricing Overview for Consent Forms

Comparison of common eSignature vendors and capabilities relevant to managing MFT informed consent forms. signNow appears first per platform comparisons.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Practical Tips for Accurate and Efficient Consent Collection

Apply consistent administrative and technical controls to reduce risk and streamline client intake.

Standardize Your Template
Maintain a single approved consent template that includes essential disclosures to avoid variance between clinicians and reduce review time.
Document Identity Verification
Use matching government ID, date of birth, and authentication methods for remote signatures to strengthen attribution and reduce disputes.
Enable Audit Trails
Capture timestamps, IP addresses, and signer actions and store the certificate of completion alongside the signed PDF for evidentiary support.
Limit PHI Sharing
Only include necessary PHI in workflows; execute a BAA before transmitting protected information to vendors.

Key Process Milestones for Consent and Recordkeeping

Track these stages from intake through long-term record retention to maintain compliance and clinical continuity.

01

Intake Signature

Obtain consent before first treatment session; confirm identity.

02

Telehealth Setup

Document telehealth consent and platform details prior to remote sessions.

03

Periodic Review

Review consent annually or when treatment scope changes.

04

Final Archive

Move signed form to secure long-term storage per retention policy.

Frequently Asked Questions About MFT Informed Consent Forms

Answers to common practical and legal questions about completing, signing, and storing consent forms for MFT practice.


Need help? Contact support

Explore Templates

California Personal Injury California Civil Case Cover Sheet Addendum and Statement of Location California Request for Dismissal California Notice of Entry of Dismissal and Proof of Service Affidavit of Occupancy California Name Change Form
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.