How to Fill Out an EMDR Informed Consent Form: Minors and Telehealth

An EMDR informed consent form is a standalone document that explains what Eye Movement Desensitization and Reprocessing involves, what the client should expect during and between sessions, and what rights the client keeps throughout treatment. It sits alongside your general therapy consent, confidentiality notice, and HIPAA privacy paperwork rather than replacing them, because EMDR uses bilateral stimulation and structured memory reprocessing that ordinary talk-therapy forms never address. A generic “I agree to psychotherapy” signature is not specific enough to cover it.

What the Form Must Disclose

APA Ethics Code Standard 10.01 requires psychologists to inform clients about the nature and anticipated course of therapy, fees, third-party involvement, and the limits of confidentiality, and to give the client a real chance to ask questions before treatment begins.¹ LPCs, LCSWs, and LMFTs face parallel duties under their state boards and the ACA Code of Ethics. On top of those baseline items, an EMDR form needs to cover:

Bilateral stimulation. Explain that the therapist will use eye movements, tactile tapping, or auditory tones presented in an alternating left-right pattern while the client focuses on a target memory. Name every form of stimulation you might use so the client can flag physical concerns such as contact lenses that dry out during sustained eye movements.²
The eight-phase protocol. Tell the client, in plain language, that EMDR moves through history-taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation. The point is not to teach the protocol; it is to make clear that EMDR is a structured sequence rather than open-ended conversation.³
The stop signal. The client can halt bilateral stimulation at any moment. This is built into the EMDR protocol during the preparation phase and needs to appear in writing.⁴
Clinician qualifications. State whether you are EMDR-trained (completed a basic training program) or hold EMDRIA Certification, the advanced credential requiring additional supervised hours and continuing education. Use EMDRIA’s exact terminology. If you are a trainee working under supervision, Standard 10.01(c) of the APA Ethics Code requires you to disclose that along with your supervisor’s name.⁵¹
Confidentiality limits and mandated reporting. These belong in your general consent too, but repeating the basics in the EMDR form prevents any argument that the client only consented to “regular therapy.”
Right to withdraw. The client can leave the counseling relationship at any time. ACA Standard A.2.a frames this as an ongoing right, not a one-time decision at intake.⁶

Risks and Side Effects To Spell Out

EMDR reprocessing does not always stay inside the session. The Adaptive Information Processing model predicts that the brain keeps integrating material after bilateral stimulation stops, so clients may notice emotional shifts, vivid dreams, surfacing memories, or physical sensations for hours or days after a session. Say this clearly. Clients who are blindsided by between-session reactions are the ones most likely to drop out or file a complaint.

Beyond between-session processing, the form should disclose:

Temporary emotional distress. Activating traumatic memories can produce intense sadness, anger, or anxiety during the session itself. For clients with severe or complex trauma, that distress can feel worse before it feels better.
Physical discomfort. Some clients report headaches, nausea, eye fatigue, or generalized tension during bilateral stimulation.
New memories surfacing. Reprocessing one memory can unlock associated memories the client did not expect to address. Note that the therapist will help process these at the appropriate time.
Medical precautions. Clients with eye conditions, heart disease, elevated blood pressure, a seizure history, or pregnancy should consult their physician before starting EMDR. Include a line asking the client to disclose any of these.

Write this section honestly without alarming the client. Most people tolerate reprocessing well, and the stop signal exists precisely for moments when they don’t.

Filling In Your Practice-Specific Fields

A template only becomes a usable legal document once you populate it with your own details. Before handing the form to a client, fill in:

Credentials and license number. List your degree (MSW, PsyD, PhD, LPC), state license number, and EMDR training status using EMDRIA’s exact terminology.⁷
Session length and fees. EMDR sessions commonly run 60 to 90 minutes rather than the standard 50-minute therapy hour, because reprocessing a memory to completion in one sitting often takes longer. If you bill under CPT code 90837 (53 minutes or longer) and charge a different rate for extended sessions, state both. Session costs typically range from $100 to $300 depending on location, credentials, and length; put your actual number on the form, not a range.
Clinical setting. Identify whether you practice solo, in a group practice, or at an agency. This tells the client who else may have access to their records and who is clinically responsible for their care.
Emergency contacts. Include your after-hours protocol and at least one local crisis hotline number. Clients experiencing distressing between-session reactions need a clear path to help outside office hours.

Consent for Minors

When the client is under 18, a parent or legal guardian must sign in most situations. There is no single federal standard for when a minor can consent independently to mental health treatment. The rules are state-specific and depend on the minor’s age, emancipation status, and living situation. Some states allow independent consent for mental health services at 12; others set the threshold at 16, and some do not permit it at all absent emancipation. Verify your state’s statute before treating anyone under 18, and keep a version of the form with a guardian signature line.

When a minor is old enough to participate meaningfully in treatment decisions, walk both the guardian and the minor through the form together even if only the guardian’s signature is legally required. The guardian should understand the same risks, side effects, and between-session processing you are describing, because they are the ones who will be with the child at home when those reactions happen.

Good Faith Estimate for Self-Pay Clients

If your client is uninsured or choosing to self-pay, the federal No Surprises Act requires you to provide a written Good Faith Estimate of expected charges before treatment begins.⁸ The GFE is not part of your EMDR consent form, but the two often get delivered at the same intake, so build the workflow together.

Timing depends on when the client schedules:

Scheduled 10 or more business days out: provide the GFE in writing within 3 business days of scheduling.
Scheduled 3 to 9 business days out: provide it within 1 business day of scheduling.⁹

Estimate the total expected cost of EMDR treatment to the extent you can reasonably project it, not just a single session. If your actual billed charges later exceed the GFE by $400 or more, the client can initiate a federal patient-provider dispute resolution process.¹⁰ Keeping the estimate realistic from the start avoids that entirely.

Extra Language for Telehealth Sessions

Virtual EMDR requires consent language that an in-office form does not cover. Bilateral stimulation delivered through a screen, whether the client follows the therapist’s finger on video, uses a light bar app, or does self-administered tapping, introduces technology variables the client needs to understand before agreeing. Add disclosures covering:

Technology risks. Internet disruptions can interrupt reprocessing mid-session. Explain your protocol for reconnecting and whether you will call the client’s phone as a backup.
Privacy limitations. The client’s environment may not be as private as your office. Ask them to confirm they are somewhere they will not be overheard or interrupted.
Client location. Collect the client’s physical address at the start of each session. If an emergency occurs during reprocessing, you need to know where to send local responders.
Cross-border licensing. If your license does not cover the state the client is sitting in during the session, you may not legally provide treatment. State this clearly.
Re-consent triggers. If the client relocates, your technology platform changes, or the treatment focus shifts substantially, get a fresh signature.

Getting the Signature

Handing someone a stack of paper and pointing at the signature line is not informed consent. It is document collection. Walk the client through each section, answer their questions, and confirm they understand what they are agreeing to.¹¹ The preparation phase of EMDR is where much of this conversation happens naturally: you are already explaining the mechanics, establishing coping strategies, and setting expectations. Treat the consent form as a companion to that clinical discussion, not a separate administrative task.

The client can sign in ink at an in-person intake or electronically through a secure client portal. The federal E-SIGN Act provides that a signature cannot be denied legal effect solely because it is in electronic form.¹² The statute itself does not require an audit trail, but HIPAA best practices call for timestamped records showing when and by whom a document was signed. Any practice management software marketed as HIPAA-compliant should handle this automatically. Once signed, give the client a dated copy, printed or digital, and keep your own copy in the clinical file.

If you are drafting rather than editing, professional liability carriers frequently provide vetted consent templates to their policyholders as part of risk management resources; check with yours before starting from scratch. APA Services offers general informed consent guidance and notes that state regulations specify minimum requirements that vary significantly between jurisdictions.¹³ Whatever template you start with, customize it to include bilateral stimulation, between-session processing, and the stop signal. A generic therapy consent will not cover any of that.

Storing the Signed Form

The completed form goes into the client’s permanent clinical record. The APA’s Record Keeping Guidelines note that both state and federal law require appropriate records of psychological services.¹⁴ There is no single federal minimum retention period for mental health records. HIPAA defers to state law, and state requirements typically run from five to ten years after the last date of service. For minor clients, many states extend the clock until the child turns 18 and then add years on top. Check your state licensing board’s rule and your malpractice insurer’s recommendation, then keep records for whichever period is longer.

When a Client Withdraws Consent

Consent is not a one-time event sealed at intake. The ACA Code of Ethics frames it as ongoing throughout the counseling relationship and affirms that clients have the freedom to leave at any time.⁶ If a client decides mid-treatment that they no longer want EMDR, whether they want to switch modalities or end therapy entirely, document the conversation and the date. A brief progress note confirming that the client withdrew consent, along with any clinical recommendations you offered, closes the loop cleanly. Trying to talk someone out of leaving, or continuing bilateral stimulation after a client has invoked the stop signal, is where ethical complaints start.

1
American Psychological Association. Ethical Principles of Psychologists and Code of Conduct
2
EMDR Institute. Dual Attention Stimuli
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American Psychological Association. Exploring the 8 Phases of EMDR
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National Center for Biotechnology Information. The Structure of EMDR Therapy: A Guide for the Therapist
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EMDR International Association. EMDR Trained vs. EMDR Certified Video
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American Counseling Association. 2014 ACA Code of Ethics
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EMDR International Association. How to Market Yourself as an EMDRIA Certified Therapist
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Centers for Medicare & Medicaid Services. Overview of Rules and Fact Sheets
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Centers for Medicare & Medicaid Services. Sample Notice of Uninsured (or Self-Pay) Individual’s Right to Receive a Good Faith Estimate
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Centers for Medicare & Medicaid Services. No Surprises Act Good Faith Estimate and Patient-Provider Dispute Resolution
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U.S. Department of Health and Human Services. Informed Consent FAQs
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Office of the Law Revision Counsel. 15 U.S.C. Chapter 96 – Electronic Signatures in Global and National Commerce
13
American Psychological Association Services. Informed Consent Guidance and Templates for Psychologists
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American Psychological Association. Record Keeping Guidelines