COVID-19 Returning to the office for appointments

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

Decision to meet Face-to-Face

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone's well-being.

If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ride-sharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting/ returning to a telehealth arrangement. Please initial each safeguard to indicate that you understand and agree to these actions:

You will only keep your in-person appointment if you are symptom-free._____
You will take your temperature before coming to each appointment. If it is elevated (100F or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I won't charge you the normal cancellation fee._____
You will wait in your car or outside until your are notified by me to enter the building._____
You will wash your hands or use alcohol-based hand sanitizer when you enter the building._____
You will adhere to the safe distancing precautions we have set up (For example, the waiting room is currently not to be used, the vinyl chairs in the office are for clients, as they are cleaned between each patient)._____
You will wear a mask in all areas of the office, unless we are seated 6 feet apart (I will too).
You will keep a distance of 6 feet and we won't be able to have physical contact (ex: we can't shake hands)._____
You will try not to touch your face or eyes with your hands, if you do, you will immediately wash or sanitize your hands (as will I if I do)._____
If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols._____
You will take steps between appointments to minimize your exposure to COVID._____
If you have a job that exposes you to other people who are infected, you will immediately let me know._____
If your commute or other responsibilities or activities put you in close contact with others (beyond your family) you will let me know._____
If a resident of your home tests positive for the infection, you will immediately let me know and we will (begin or) resume treatment via telehealth.

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My commitment to Minimize Exposure

My colleagues and I have taken steps to reduce the risk of spreading coronavirus within the office and I have posted these efforts in my office. Please let me know if you have questions about these efforts.

If You or I Are Sick

You understand that I am committed to keeping you, me, my other patients, and all of our families safe from the spread of the virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe that you have been exposed, I will have to require you to leave the office; we can follow up with services by telehealth as appropriate.

If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the case of Infection

If you or I have tested positive for the coronavirus, you or I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide minimum information necessary for their date collection and will not go into any details about the reason for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

Informed Consent

This agreement supplements the general information consent/business agreement that we agreed to at the start of our work together.

Your signature below shows that you agree to these terms and conditions.

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Patient

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Therapist

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