Access our free Client Consent Form template with placeholders you can customize to fit your agency’s needs.

[Agency Name]

[Agency address and contact information]

Client Consent Form

Client Information
Client Full Name: __________________________________________ Date of Birth: ____________________________
Address: _______________________________________________ Phone Number: ____________________________
Email Address (optional): ____________________________________________________________________________

1. Consent for Services

I, [Client Name], consent to receive services provided by [Agency Name] as agreed upon in my Individual Service Plan (ISP) or other outlined care agreements. I understand that services may include, but are not limited to, personal care, companion services, respite care, and other approved assistance based on my unique needs.

Client Signature: _____________________________________ Date: _________________________________________

2. Consent for Data Sharing and Communication

I, [Client Name], consent to [Agency Name] collecting, using, and sharing my personal health information as required to provide high-quality services, coordinate care, and comply with regulatory requirements. I understand that:

• My information may be shared with healthcare providers, insurance providers, and other agencies when necessary for care or compliance.
• All information shared will be protected in compliance with HIPAA and other relevant privacy laws.

Client Signature: ____________________________________ Date: _____________________________________________

3. Emergency Contact and Authorization

I authorize [Agency Name] to contact the individual(s) listed below in case of an emergency.

• Emergency Contact Name: __________________________________
• Relationship to Client: ______________________________________
• Phone Number: ___________________________________________

4. Consent for Photography/Videography (Optional)

I, [Client Name], give [Agency Name] permission to take photographs or video recordings of me for purposes of care documentation, training, or agency promotional material. I understand I may withdraw this consent at any time by providing written notice.

Client Signature: ____________________________ Date: ____________________________

5. Acknowledgment of Client Rights and Responsibilities

I have received and understand the information regarding my rights and responsibilities as a client of [Agency Name].

Client Signature: ____________________________ Date: ____________________________

6. Additional Consents (Optional)

Please check any that apply:

• ☐ I consent to receive reminders and service updates by text message.
• ☐ I authorize [Agency Name] to leave messages on my voicemail or with family members listed in my records.
• ☐ I consent to participate in surveys for quality improvement purposes.

7. Signature and Date

By signing below, I acknowledge that I have read, understood, and agree to the terms outlined in this Consent Form. I understand that I may revoke this consent at any time in writing.

Client Signature: ____________________________ Date: ________________________________

Authorized Representative Signature (if applicable): ______________________________________
Relationship to Client: ____________________________ Date: ____________________________

You may reach out to us for a more customized form based on your state-specific regulation. Call us at 302.888.9172 or email licensing@waivergroup.com for assistance.