Informed Consent to Treatment: Do Not Practice Without It
Clinical Update June 2015
By Zur Institute
In recent weeks, I have consulted with several attorneys from several different states. These attorneys were desperately defending psychotherapists and counselors against licensing boards who wanted to take their licenses away for the simple reason of practicing below the standard of care by not having a documented Informed Consent to Treatment by clients at the very beginning of treatment.
I have encountered many similar situations over the years of practicing forensic psychology, and find it hard to believe that in 2015 there are still psychotherapists and counselors, who leave themselves vulnerable by not making a very minimal investment of time and money to employ Informed Consent with their clients.
The informed consent should include, but should not be limited to, sections such as confidentiality, limits to confidentiality, duty to report, fees & insurance, theoretical orientations or treatment modalities used, risk and benefits of treatment, cancellation policy, use of phone, emergency procedures, videoconferencing, text, e-mail and social media in therapy, scope of practice, termination, and more. (Many therapists, insufficiently use a one-page informed consent that is unlikely to comply with the standard of care.)
You do not need to re-invent the wheel. We, at the Zur Institute, have a 5-page Informed Consent form (updated in 2018), which is part of 60 Essential Clinical Forms that you can adapt for your practice.
The Clinical Forms are also available as part of a 6 CE credit online course on Record Keeping.
- When you are ready to use your new, revised, or updated Informed Consent make sure that you use it not only with new clients, but also with current clients, even though they have been in treatment for awhile and did not sign an Informed Consent at the onset of their treatment (do not predate it, use the correct-current date).
- While some codes of ethics or state laws may not specify that therapists must have a written/signed informed consent, having a signed hard copy form is the easiest and simplest way to prove compliance in this area with the codes of ethics and the standard of care.
- While informed consent is an ongoing process, it starts with the above-mentioned form and a conversation and continues through dialogues as therapy evolves and/or conditions change (document these conversations in clients’ progress notes).
- Informed Consents vary between different types of practices, settings and even between different clients.
Samples of other important clinical forms included in our package of 60 Essential Forms:
- Form #2: Biographical Questionnaire: Have your client fill out this 3-page questionnaire before the first session. You need this information in your clients’ clinical files.
- Form #5: Initial Assessment – After the first session: This simple 2-page form includes a mental status exam, DX or focus of treatment, basic treatment plan, and more.
- Form #17: Authorization to Release Information: You should never release information before your clients sign this form (unless it is required by the law).
- Form #24: Termination Summary: This basic form must be filled out and placed in the clinical file for each client with whom you have terminated.
- Form #44 and 45: Treatment Plan: A simple to fill out 2-page form, articulating your DX impressions or focus of treatment, identifying short- and long-term goals, and outlining the type of intervention you intend to use.
- Form #52: Professional Will: Prepare for the unexpected and unavoidable. It is unethical to practice without such a will and can cause major problems to your loved ones and your estate.