COVID-19 Consent Form

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 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 agreement between us. 

 

Decision to Meet Face to Face

We’ve 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, we may have to reschedule our appointments. 

 

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, and other patients) safer from exposure, sickness and possible death. Your failure or refusal to adhere to these safeguards may result in our rescheduling for a later time when it is safe to meet in the office.  Initial each 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 (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment.  If you wish to cancel for this reason, I won’t charge you our normal cancellation fee. __
  • You will wait in your car until I text or call you to enter the building. ___
  • You will wash your hands or use hand sanitizer when you enter the building. ___
  • You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.___
  • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) withme. ___
  • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. ___
  • 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. ___
  • If you have a job that exposes you to those who are infected, you will 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 reschedule for a later time.___

 

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 practice has taken steps to reduce the risk of spreading the virus within the office and we have posted our efforts on our website and in the 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, 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. 

 

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 of 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 to 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. 

 

 

 

_________________________                                              _________________________

Patient/Client                                                                          Date

 

_________________________                                              _________________________

Psychologist                                                                            Date

 

 

 

 

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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