Private Practice Forms: Policies and Procedures Explained

If you’re a therapist running your own practice, it’s important to begin with clear policies and rules in your intake documents. Starting a practice may seem like a lot at first, but covering everything well can help you manage your practice better.

What you decide to list in your practice policies will depend on your location and what you think is necessary. Many therapists choose to include their policies in the informed consent forms. Some may also add extra documents to share more details.

Some therapists ask a lawyer to go over their documents to make sure they meet legal standards. Others might look at how fellow professionals write their forms and use that as a reference.

Key Sections for Private Practice Counseling Forms

Below is a list of essentials that therapists in private practice might add to their forms. You can change these based on the setup and focus of your practice.

Introducing Yourself to Clients

You might want to add a section about yourself in the informed consent form. This part might cover:

• Some personal background

• How long you’ve worked in the field

• Education and certifications

• Your methods of treatment

• Your counseling approach

• What clients can expect from sessions

• The specific group or concern you focus on

This part helps clients understand your background, where you trained, and what it’s like to work with you.

Explaining the Pros and Cons of Therapy

This section should give clients a sense of what therapy involves and what part they play in the process. It also explains what your role is as their therapist and the good and bad sides of regular treatment.

Here, you can also talk about which methods you use, how you build trust with clients, and how therapy goals are set. You might explain how you guide clients toward meeting those goals.

Setting Fees and Payment Rules

Your policy documents should have a section explaining how much sessions cost. Your session rate and the rules for missed payments or declined cards should be included. You might also add your no-show or late cancellation policy here.

If you charge a fee for cancellations or need a certain amount of notice, that should go in this section too. Also, you can explain fees for things like record requests or court-related work.

Explaining the Good Faith Estimate (GFE)

If your practice is private pay only, you must give clients a Good Faith Estimate. This document lists the likely cost of therapy. It usually stays valid for up to a year.

The goal of the Good Faith Estimate is to clearly show clients what to expect in terms of cost. If their final bill is over $400 higher than the estimate, they can raise a concern about it.

It’s important to give the most accurate estimate you can. Providers may choose different time periods. I list prices for one session, and for sessions over three, six, nine, and twelve months. I also give two pricing options—weekly and bi-weekly visits. This applies to all private pay practices.

How to Reach You Between Appointments

If you run a private therapy practice, it’s a good idea to explain how clients can get in touch with you between sessions. Some therapists have specific guidelines about texts or emails outside session times. If you charge for those interactions, this should be explained clearly.

You should also include guidance for what clients should do in a crisis or emergency. You might want to list local, state, or national emergency lines here so clients have them if needed.

Adding Details About Virtual Sessions

If you use video calls for therapy, it’s smart to include details about that in your policy documents. Clients should know what virtual sessions involve and what risks may come with them.

You can add points such as:

• How secure video calls are

• Which platform you use

• Steps taken to keep client info private

• Why having a quiet and private space helps with online therapy

• What to do if your video call setup stops working

• Limits of online therapy, like needing to be in a state where you are licensed, unless exceptions apply

Many therapists add this in the informed consent. Your clients should be clear on what virtual sessions can and cannot offer.

When Privacy May Not Be Guaranteed

Trust is key in therapy. Studies in 2020 still show that the strength of the therapist-client relationship has a big impact. That’s why it’s important to clearly explain when confidentiality might be broken.

Though this can vary by state, common situations where privacy can be broken include:

• When a client is a risk to themselves or others

• If abuse of children, elders, or protected individuals is suspected

• If there is a duty to warn someone of possible harm

• When there’s a court order for records or testimony

• When records are needed for billing insurance

You might also talk with other professionals to improve your skills. In those cases, you usually remove identifying details. If you do this, tell the client ahead of time.

If your state has specific rules, include those as well. This is especially important if you work with children or teens.

Planning for the Unexpected

If you can’t keep working due to illness or death, your clients should know who to contact. This is something many therapists forget, as it can be hard to think about. Still, life is uncertain, so it’s wise to prepare your clients just in case.

Some professionals choose a trusted therapist to take over if they cannot continue. It may also help to work with a lawyer to prepare a professional will that handles these situations.

Social Media Use and Boundaries

Since social media plays a large role today, setting rules around it is necessary. You should make it clear that it’s not okay to be friends with clients on personal accounts. As a therapist, it’s important to be aware of how your online presence might affect your clients.

You can include a statement that you won’t accept friend requests, but that you might have work-related pages they can choose to follow. Clients should understand that following such pages is optional and might reveal their identity to others.

Letting Clients Know Their Rights

Before therapy starts, clients need to be aware of their rights. Adding a list of these in your forms or consent papers helps inform clients of what they can expect.

As outlined by the National Board of Certified Counselors, client rights include:

• Being able to ask questions about therapy

• Knowing how therapy works and what’s used

• Being informed about fees and payment rules

• Having confidentiality, with few exceptions

• Getting a notice about privacy practices

• Access to the therapist’s code of ethics

• Being able to ask questions about methods used

• Knowing the limits of privacy

• Getting copies of their records if they ask

Clients should be fully aware of these rights while receiving care.

Concerns and Complaints 

If clients have any concerns or think their rights were not respected, you can explain what steps they can take. Most therapists ask clients to talk directly to them about their concerns first.

If a client isn’t comfortable doing that, you can share how they can file a formal report with the board that manages therapist licenses. For example, I’m licensed in Missouri and Kansas, and clients can report issues to the proper board in each state.

I include both board numbers in my consent form and explain how clients can get in touch with them. If you're a psychologist, psychiatrist, or social worker, the process may be different depending on your profession and state.

Informing Clients of Privacy Rules

Clients should be given a copy of your privacy notice. This document tells them how their mental health data is shared. It should also include details about what’s sent to insurance companies or shared with others who may be involved in their care.

Sharing Information with Others

If you plan to speak with other providers or get information from them, you’ll need a release of information (ROI) form. This is a basic form often used in therapy settings. You can create your own or find a reliable template to use.

Keeping Client Records Safe and Legal

Your policies should include how long you keep client files, as required by local laws and ethical standards. Most states have rules about record storage time. Make sure your record-keeping follows legal and ethical expectations.

Working with Insurance Providers

If you bill insurance, make sure your policy covers which insurance plans you accept, how co-pays are collected, whether you give superbills, and how coverage is confirmed.

Clients should also know what details are shared with their insurance provider. A good place to share this is within your privacy notice.

Final Thoughts

Starting your own practice and figuring out what documents to prepare can feel like a lot. Your informed consent will include many of your policies, and the areas above offer a basic guide. You may add more depending on your needs.

As your practice grows, you might find that your forms need changes. You may also want to learn more about setting up a practice beyond the paperwork. If you’re interested in software that helps with writing progress notes, you might try out SOAPsuds AI Medical Scribe free.

Before finalizing your paperwork, review the rules and laws that apply to your license and location. Giving clients clear information and holding yourself to strong standards helps keep things healthy for both you and your clients.