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

  • Informed Consent

    This document contains important information about our decision (yours and mine) to resume inperson 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 zoom! You understand that, if I believe it is necessary, I may determine that we return to an online platform for everyone’s well-being. If you decide at any time that you would feel safer staying with, or returning to, remote services, I will respect that decision, as long as it is feasible and clinically appropriate. Fees for service will remain the same unless otherwise discussed and agreed upon.

    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 ridesharing 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, my office mates 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 remote sessions.

    Initial each to indicate that you understand and agree to these actions:
  • 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.

    If You or I Are Sick


    You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services remotely 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 have tested positive for the coronavirus, 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 the minimum information necessary for their data collection and will not go into any details about the reason(s) 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 informed 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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  • Office Safety Precautions in Effect During the Pandemic My office is taking the following precautions to protect our patients and help slow the spread of the coronavirus.
    • Office seating in the waiting room and in therapy rooms has been arranged for appropriate physical distancing.
    • I will wear a plastic face shield or mask.
    • Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
    • We schedule appointments at specific intervals to minimize the number of people in the waiting room.
    • We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.
    • Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized after each use.
    • Physical contact is not permitted.
    • Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
    • Common areas are thoroughly disinfected at the end of each day and wiped down between clients.