This form is intended to allow you to give informed consent to have in-person services during the ongoing COVID-19 public health crisis. Read it entirely and make sure that all of your questions are answered before signing to give consent.
*The guidelines and requirements in this document are regardless of vaccination status.*
Returning to In-Person Sessions
Although we are offering in-person sessions at this time, if there is a resurgence in COVID-19 or if the local or federal government or the CDC recommends that in-person sessions be limited or suspended, we will comply with these recommendations and may request that your in-person sessions be changed to telehealth visits with your provider.
If you have questions or concerns about telehealth as an option for you, please inform your provider. You may request to resume or begin telehealth at any time if you would feel more comfortable seeing your provider virtually rather than in person. You are responsible for knowing your insurance coverage or limitations for telehealth sessions.
Risks of Returning to In-Person Sessions
Although we are taking appropriate precautions, by coming to the office for in-person sessions, you are assuming a certain level of risk, which includes possible exposure to COVID-19 or other illnesses.
If your provider believes that you have a fever, are experiencing symptoms of COVID-19 or other illnesses, that you have not disclosed, or are otherwise putting yourself and your provider at risk, they may ask you to leave the office.
Client’s Responsibility to Minimize Exposure
These responsibilities may change in accordance with local, state, or federal guidelines. Any changes will be communicated to you promptly, and any questions that you may have will be discussed at that time.
- You will only keep your in-person appointment as scheduled if you are symptom-free. These symptoms include, fever or feverish feelings within the past 21 days; shortness of breath, difficulty breathing, cough, or any other flu-like symptoms like gastrointestinal upset, headache, or fatigue; and recent loss of taste and/or smell. You will not attend an in-person appointment if you have come into recent contact with a COVID-19-positive person, or if you have traveled outside of the state in the past 14 days (subject to change based on current CDC and DOH guidelines).
- You will maintain a distance of 6 feet from all providers and members of staff when possible, and you will not initiate physical contact (shaking hands, etc.)
- You will only bring people with you into the building that will be included as part of your counseling session.
- If you currently work in a field that requires you to have close or frequent contact with individuals outside of your immediate household, you will inform your provider and discuss whether the risk is acceptable to both of you to be doing in-person sessions.
- If a member of your household, or you yourself, test positive for COVID-19, you will let your provider and the office know as soon as possible, and all sessions will be changed to telehealth or canceled, as needed.
Our Responsibility to Minimize Exposure
- We will schedule appointments at specific intervals to minimize the number of clients in the office at one time.
- All offices will have hand sanitizer available that contains at least 60% alcohol.
- Tissues and trash bins are easily accessible. Trash is disposed of on a frequent basis.
- Credit card pads, pens, and other areas that are commonly touched are thoroughly sanitized after each use.
- Common areas will be disinfected throughout the day as well as at the end of each day
- If your provider is experiencing any symptoms, you will be called to move your appointment to telehealth or reschedule the in-person session until after they are no longer experiencing symptoms or have a negative COVID-19 test result and have followed the doctors recommendations for quarantine.
In the Event of Exposure
We are committed to keeping ourselves and our clients as safe as possible. If any of our providers or members of staff test positive for COVID-19, we will inform you so that you can take appropriate precautions as soon as possible.
Confidentiality in the Case of Infection
If you or a member of our staff have tested positive for COVID-19, we may be required to notify local health authorities that you have been in the office. If we do report this, we will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for your visit to the office. By signing this form, you are agreeing to this release of information without the need for an additional signed release. Please sign below to indicate that you have read and understood the information above, and that you have asked any relevant questions.