Center for Psychological Development (CPD3)
Consent for Returning to In-Person Psychological Services
This Consent for Returning to In-Person Psychological Services is a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Please read this document carefully, and let us know if you have any questions.
The threat of COVID-19 is onging throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, teletherapy services may not be adequate, and in-person services may be more appropriate.
We have determined that in-person services are appropriate at this time for your situation for the following reason(s):
[ ] Client has pressing clinical needs which are better addressed in person
[ ] Client is not benefitting from remote service
[ ] Technology is not available or reception is poor
[ ] Client insurance stopped covering telemedicine
The decision about whether to engage in in-person services is based on current conditions and guidelines, which may change at any time. It is possible that a return to remote services will be necessary at some point based on consideration of health and safety issues. Such a decision will be made in consultation with you, but we will make the final determination based on a careful weighing of the risks and applicable regulations.
It is also important to consider that, although insurance reimbursement for teletherapy services may have been madated during the COVID-19 pandemic, such mandates may no longer be in effect, and teletherapy may no longer be reimbursed by your insurance company.
In order for us to provide you with in-person services, the following protocols must be followed by patients/clients and providers:
*Social distancing requirements must be met, meaning that you must maintain a six-foot distance from others while in offices, waiting rooms, and other areas.
*A staff member will take your temperature at the office entrance.
*Hand sanitizer will be provided at the office entrance and must be used upon entering the building. An alternative is hand-washing in the restroom.
*Clients and therapists will be required to wear face coverings/masks while in the office. If you do not have a face covering, one will be provided to you.
*There will be no physical contact with others in the office.
*You will be asked to wait in your vehicle or outside the office until your appointment time.
*You agree not to present for in-person services if you have a fever, shortness of breath, coughing, or any other symptoms associated with COVID-19 or if you have been exposed to another person who is showing signs of infection or has confirmed COVID-19 within the past two weeks.
*If you are bringing a child or other dependent in for services, you agree to ensure that both you and your child/dependent follow all of these protocols.
*You will be asked to make payment remotely (phone, mail or online) prior to or immediately following your appointment.
As COVID-19 regulations continue to evolve, we may become legally required to disclose that you and your therapist have been in contact, especially if either party were to test positive or show signs of COVID-19 infection. If we are legally compelled to disclose information, we will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law.
We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let your therapist know.
By signing below, you acknowledge that you understand that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services.