Informed Consent Best Practices: Beyond the Signature

Written By Stuart Kaplowitz

Why Informed Consent Is More Than a Form

Informed consent is not simply a signed document. It is an ongoing ethical conversation that establishes trust, autonomy, and legal clarity.

When done correctly, informed consent:

  • Reduces malpractice risk

  • Clarifies therapeutic boundaries

  • Protects client autonomy

  • Strengthens the therapeutic alliance

When treated as a formality, it becomes a liability risk.

Core Components of Ethical Informed Consent

Every informed consent process should clearly outline:

Nature of Treatment

  • Modalities used

  • Treatment goals

  • Expected duration

Risks and Benefits

Clients must understand potential discomfort, emotional distress, or therapeutic challenges.

Confidentiality and Limits

Including:

  • Mandatory reporting

  • Duty to warn

  • Subpoena scenarios

Fees and Policies

Clear financial agreements reduce future disputes.

For therapists in private practice, clear documentation is critical for risk management.

Learn more about our clinical services and collaborative care model here:
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Ongoing Consent: A Dynamic Process

Informed consent should be revisited when:

  • Introducing new interventions

  • Transitioning to telehealth

  • Adding group or family members

  • Addressing high-risk disclosures

Document these conversations thoroughly.

Documentation Best Practices

To reduce liability:

  • Note verbal discussions about risks

  • Document client questions

  • Record consent updates

  • Store signed forms securely

  • Reference consent review in progress notes

Thorough documentation demonstrates ethical diligence if ever reviewed.

Telehealth Considerations

With digital therapy, consent must address:

  • Platform security

  • Emergency procedures

  • Technology risks

  • Geographic licensing compliance

Telehealth documentation must be explicit and state-specific.

Common Pitfalls to Avoid

  • Using overly technical language

  • Failing to confirm comprehension

  • Treating consent as one-time

  • Not updating policies annually

  • Ignoring cultural considerations

Ethical informed consent adapts to client needs.

Strengthening Client Understanding

Best practices include:

  • Using plain language

  • Encouraging questions

  • Checking comprehension

  • Offering written summaries

  • Reviewing annually

Clear communication protects both therapist and client.

Risk Management Through Clarity

Informed consent is a preventative strategy. It reduces ambiguity, strengthens transparency, and reinforces professional credibility.

Clinicians seeking structured, ethical practice environments can explore opportunities or collaborative care options at:
https://www.serenepathways.com/contact

Ethical Practice Builds Sustainable Careers

When informed consent is done well, it enhances:

  • Client trust

  • Treatment clarity

  • Legal protection

  • Professional confidence

It is not administrative overhead. It is foundational ethical care.

Explore our free mental health resources. They may benefit your patients or clients.

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📞 909-591-5085 | 📧 Stuartkaplowitz@serenepathways.com
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Stuart Kaplowitz
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Why Informed Consent Matters