INFORMED CONSENT FOR IN-PERSON SERVICES
This document contains important information about our decision (yours and mine) to begin/resume in-person services in light of the COVID-19 public health crisis. Our decision is based in part on recommendations by the Center for Disease Control (CDC), but other factors may be considered. Some of these include but are not limited to: whether we and our families have been vaccinated, our health or the health of those we are in close contact with, and risk of exposure outside of this setting. There may be other concerns that we can talk about.
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
You (on behalf of yourself or your child) have requested 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 all or some of our future sessions be held via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.
If you decide at any time that you would prefer you or your child to stay with, or return to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate.
Risks of Opting for In-Person Services
You understand that by coming to the office/meeting in person, you, and/or on behalf of your child, are assuming the risk of exposure to the coronavirus or other public health risk. This risk may increase if you and/or your child travel by public transportation, cab, or ride-sharing service.
Your Responsibility to Minimize Your/Your Child's Covid-19 Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone safer from exposure, sickness and possible death. If you/your child do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.
* You will tell me if you/your child have been vaccinated. If you/they haven’t, we’ll talk about the reasons and whether it’s possible to meet safely in person
* You will only keep your/your child's in-person appointment if you/they are symptom free.
* You will only keep your in-person appointment if you have been fever free for a minimum of 10 days prior to our appointment.
* You will cancel your appointment if you have been in contact with someone who has tested positive within the last 14 days.
* You will take your/your child’s temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you/your child have other symptoms of the coronavirus, you agree to cancel the appointment with 24 hours notice or proceed using telehealth.
* You/your child will wait in your car or outside until no earlier than 5 minutes before our appointment time.
* You/your child will wash your/their hands or use alcohol-based hand sanitizer when entering the building.
* You/your child will adhere to the safe distancing precautions we have set up in the waiting room and therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.
* You/your child and I will wear a mask in all areas of the building, regardless of vaccination status.
* You/your child and I will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands)
* You/your child will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands
* You/your child will take steps between appointments to minimize your/their exposure to COVID
* If you have a job that exposes you to other people who are infected, you will immediately 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 then begin or resume treatment via telehealth.
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 office and I have taken steps to reduce the risk of spreading the coronavirus within the office and I have posted our efforts on my website and in the office. Please let me know if you have questions about these efforts.
If You/Your Child or I Are Sick
You understand that I am committed to keeping you/your child and me and all of our families safe from the spread of any infectious microbe. If you/your child show up for an appointment and I believe that you/they have a fever or other symptoms, or believe you/they have been exposed, I will have to require you/them to leave the office immediately. We can follow up with services by telehealth as appropriate.
If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
Your/Your Child's Confidentiality in the Case of Infection
If you/your child have tested positive for the coronavirus, I may be required to notify local health authorities that you/they 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.
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.