What is Tarasoff duty?

A duty (named after the 1976 California case Tarasoff v. Regents) requiring mental-health providers to warn or protect identifiable third parties from credible threats made by a patient. State versions vary — some states impose a duty to warn, some a duty to protect, some neither. Where the duty applies, providers may breach confidentiality to take protective steps (warn the target, hospitalise the patient, notify police). Most cases involve specific named threats with means and intent; vague hostility usually does not trigger the duty.

Can my therapist share information with my primary-care doctor?

Only with your written consent. Continuity-of-care sharing between mental-health and physical-health providers is encouraged but generally requires separate authorisation under HIPAA and stricter state laws. Many patients sign the authorisation as part of intake; you can also revoke at any time. Some practices use integrated EHRs where notes are technically visible across the system; ask if so.

What about telehealth across state lines?

Most state psychology, counselling, and social-work boards require the provider to be licensed in the state where the patient is physically located during the session. PSYPACT (the interstate Psychology Compact) allows licensed psychologists in member states to practise across PSYPACT-state lines (40+ states as of 2026); similar compacts exist for counsellors (Counseling Compact) and social workers (Social Work Compact) with varying state participation. Outside these compacts, treating an out-of-state patient is generally a license violation. Discuss your travel and residence patterns with the provider.

Can I refuse a specific medication or intervention?

Yes — informed consent includes the right to refuse. The provider should describe alternatives and the consequences of refusal. Refusing a recommended medication does not generally end treatment, but in some severe cases (acute psychosis, severe depression with suicidality) the provider may recommend transferring to a higher level of care if the refusal makes outpatient treatment unsafe.

What if I don't want my insurance company to know I'm in therapy?

Self-pay (out-of-pocket) means the insurer never receives a claim. Many practices offer a "self-pay" rate; some offer sliding-scale fees. Note that self-pay does not entitle the practice to charge MORE than the insurance contracted rate (most contracts require offering the lower of the two). The trade-off is full out-of-pocket cost vs. complete privacy from the insurer's records.

Mental Health Treatment Consent

Informed consent for mental-health treatment — therapy, medication management, telehealth.

Customise

Provider / practice name

Treating provider — name + credentials

License jurisdiction

Patient — full name

Patient — DOB

Date of consent

Treatment type

Treatment approach (e.g. CBT, ACT, EMDR, psychodynamic)

Session frequency and duration

Fees and insurance

Confidentiality scope and exceptions

Risks and benefits of treatment

Telehealth-specific consent (if applicable)

Patient acknowledgements (one per line)

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RIVERSIDE BEHAVIORAL HEALTH

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INFORMED CONSENT FOR MENTAL-HEALTH TREATMENT

Patient: Jordan Alex Taylor
DOB: June 12, 1985
Provider: Dr. Maria Sanchez, PsyD, Licensed Psychologist (OR #PSY-3304)
License jurisdiction: Oregon Board of Psychology — license active and in good standing.
Date of consent: May 4, 2026

1. TREATMENT TYPE AND APPROACH

Treatment type: Individual psychotherapy
Approach: Cognitive Behavioural Therapy (CBT) with elements of Mindfulness-Based Stress Reduction (MBSR), as clinically indicated.
Frequency / duration: Weekly 50-minute sessions for the first 8 weeks, then re-evaluation. Crisis sessions available between regular appointments by phone.

2. FEES AND INSURANCE

Self-pay rate: $185 per 50-minute session, $250 for 90-minute intake.
Insurance: in-network with BCBSOR, Pacific Source, Moda Health, Providence. Out-of-network with most other plans (superbill provided for reimbursement).
No-show / late-cancellation policy: $100 fee for cancellations less than 24 hours' notice (insurance does not cover).

3. CONFIDENTIALITY AND ITS LIMITS

Communications during treatment are protected by HIPAA, state psychotherapy-patient privilege, and the practice's privacy policy. Confidentiality exceptions REQUIRED by law:
• Imminent risk of harm to self or others (mandatory reporting / Tarasoff duties).
• Suspected child, elder, or dependent-adult abuse (mandatory reporter).
• Court-issued subpoena or court order.
• Insurance claim (limited disclosure of diagnosis, dates, type — not session content).
• Continuity of care (with patient written consent).

4. RISKS AND BENEFITS

BENEFITS may include: reduction in symptoms (anxiety, depression, etc.), improved coping, improved relationships, increased self-understanding, improved functioning. Outcomes vary; no specific result is guaranteed.
RISKS may include: temporary increase in distress as difficult material is processed, changes in relationships as patterns shift, occasional sense of being unsettled between sessions. Medication-management risks (if applicable) are discussed separately when prescribing.

5. TELEHEALTH (if applicable)

Telehealth sessions are conducted via a HIPAA-compliant video platform. Patient is responsible for ensuring a private location during sessions and reliable internet connectivity. Patient understands that:
• Telehealth has technological limitations (audio/video drops, security incidents).
• Provider is licensed in Oregon; out-of-state sessions may not be permitted under interstate-licensing rules.
• In a crisis, telehealth is not a substitute for in-person emergency services. Patient should call 988 (Suicide & Crisis Lifeline) or 911 in an emergency.

6. PATIENT ACKNOWLEDGEMENTS

- I have read and understand the information above.
- I have had the opportunity to ask questions and have those questions answered.
- I voluntarily consent to the treatment described.
- I understand I may withdraw consent and end treatment at any time.
- I understand I have a right to seek a second opinion or change providers.
- I have received a copy of this consent form and the practice's Notice of Privacy Practices.

7. EMERGENCY CONTACTS

In a mental-health crisis between sessions:

• Suicide & Crisis Lifeline: 988 (call or text)
• Crisis Text Line: Text HOME to 741741
• Local crisis line: ____________________ (your state/region)
• Local emergency: 911

This provider does NOT provide emergency / crisis-line coverage. Use the resources above for after-hours crises.

8. SIGNATURE

_______________________________ Date: ____________________
Jordan Alex Taylor (Patient — or guardian for minor)

_______________________________ Date: ____________________
Dr. Maria Sanchez, PsyD, Licensed Psychologist (OR #PSY-3304)

About this template

Mental-health treatment requires informed consent that goes beyond the general consent-to-treatment used in primary care. Three areas demand more detail. First, confidentiality and its limits: psychotherapy notes have stronger HIPAA protection than standard medical records (45 CFR §164.508(a)(2) requires separate authorisation for release), but mandatory-reporting duties (imminent harm to self/others, child/elder/dependent abuse, Tarasoff duties to warn third parties of credible threats) override that protection. Patients must understand these exceptions before treatment begins. Second, the nature of psychotherapy itself includes risks (temporary increase in distress as difficult material surfaces, shifts in relationships) that medical patients may not anticipate. Third, telehealth — now the default for many therapy practices — has unique consent requirements: licensure jurisdiction (a therapist licensed in one state generally cannot treat patients physically located in another state under most state psychology and counsellor boards), technology limitations, privacy of the patient's setting, and crisis-response limitations are all topics that interstate-telehealth-compact law and individual state boards now require disclosure on. Medication management adds prescribing risks (FDA black-box warnings on antidepressants for under-25s, dependence/withdrawal on benzodiazepines and stimulants, drug interactions) that should be addressed at the time of prescribing rather than buried in a general consent. Patients have rights — including the right to end treatment, change providers, request records, and refuse specific interventions — that should be stated on the consent form rather than only in the Notice of Privacy Practices.

When to use it

Starting therapy with a new provider.
Beginning psychiatric medication management.
Switching to telehealth from in-person (or vice versa).
Significant change in treatment approach or modality.
Annual update at an established practice (most refresh consent yearly).

What to include

Treatment type, approach, frequency.
Fees, insurance, no-show policy.
Confidentiality scope and mandatory-reporting exceptions.
Risks and benefits of treatment.
Telehealth-specific consent (if applicable).
Crisis resources (988, Crisis Text Line, 911).

Frequently asked

Federal HIPAA gives psychotherapy notes stronger protection than standard medical records — 45 CFR §164.508(a)(2) requires separate, specific authorisation for psychotherapy notes, and they cannot be released to insurance companies for routine claims. State law often expands protection further. The exceptions are mandatory-reporting situations (harm to self/others, abuse, court order) that override the standard protection. Discuss the specific exceptions with your provider before disclosing sensitive material.

⚠ Legal disclaimer. Mental-health informed consent is regulated by state psychology, counselling, social-work, and medical boards in addition to HIPAA. Telehealth consent has rapidly-evolving requirements with state interstate compacts (PSYPACT, Counseling Compact, Social Work Compact) and individual state board rules; check provider licensure for the state where the patient is physically located. Medication-management consent should be addressed separately at the time of prescribing each medication, with FDA black-box warnings, dependence/withdrawal information, and drug interactions specifically disclosed. For minor patients, additional state-law rules govern who can consent (often a complex mix of parental and minor consent for ages 14+ depending on state and treatment type).