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 me know if you have any questions.
The threat of COVID-19 is ongoing 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):
- Insurance Coverage
- Based on your clinical circumstances
- Limitations around therapy at place of residence (lack of privacy, poor internet connections, etc).
- Our practice’s compliance with CDC guidelines can be strictly enforced at this time
- Any other reason___________________________________
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 I 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 mandated 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 me 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.
- Patients/clients and providers will be required to wear face coverings or masks while in the office. If you do not have a face covering, one will be provided to you.
- Hand sanitizer will be provided at the office entrance and must be used upon entering the office.
- There will be no physical contact with others in the office.
- You will be asked to wait in your vehicle or outside the office suite (outside in the lobbies of the buidings) until you receive a text, email, or phone call from office staff indicating that you can enter the office.
- 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.
- Please do not bring pets, non-essential companions, or others to your sessions. We are trying our best to minimize contact with others.
- Please complete a credit card form to keep on file so our office can charge your balance to reduce the need to transfer cash/checks between us.
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 me 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. And, as a condition of receiving services from us, you agree to indemnify, hold harmless, protect and defend, and unconditionally release, acquit, waive and forever discharge Michelle Chaban, PC; DBA: Associates In Psychotherapy, its employees, and its representatives from any and all claims, liabilities, losses, damages, suits, costs, and expenses (including reasonable attorney’s fees) relating to your failure to follow our instructions, or relating to any act, or failure to act by Michelle Chaban, PC; DBA: Associates In Psychotherapy, its employees, and its representatives, or that may otherwise be connected to the entity as it relates to COVID-19. You agree to assume all associated risks of injury or death associated with COVID-19. The terms of this indemnification policy shall survive the expiration of any therapeutic relationship with us. You understand that we cannot guarantee that you will not become infected with COVID-19 upon entrance into our facility, even if you have been fully vaccinated against COVID-19. You are voluntarily seeking out the services offered by us and acknowledge that you may be increasing your risk of exposure to COVID-19. You understand that you must comply with all of our policies and procedures to reduce the spread of COVID-19 while attending your session, including wearing a mask when asked.