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 COVID-19 public health crisis. Please read this carefully and feel free to ask questions or express concerns. When you sign this document, it will be an official agreement between you and 20/20 Counseling, LLC.
Decision to Meet Face-to-Face
We have 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, it may require that we suspend sessions or meet via telehealth. This decision will be made in order to insure everyone’s well-being.
If you decide at any time that you would feel safer beginning , staying with or returning to telelhealth 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, 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 safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may become necessary to use telehealth services. Please review the safeguards below.
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 or proceed using telehealth. If you need to cancel for this reason, there will be no cancellation fee.
If you have been unable to check your temperature before coming to your scheduled appointment, you will agree to check using the infrared thermometer available in our office.
You will wait until no earlier than 5 minutes before your appointment time before entering the office waiting area.
You will use the provided alcohol based hand sanitizer when entering the office.
You will adhere to safe distancing precautions.
You will wear a mask in all areas of the office.
You will take steps between appointments to minimize your exposure to COVID.
If a resident your home or others you have had contact with, tests positive for the virus, you will immediately let me know and we will resume treatment via telehealth or suspend treatment until the health risk has passed.
The above precautions may change if additional local, state, or federal orders or guidelines are published. If needed, we will talk about any necessary changes.
Our Commitment to Minimize Exposure
20/20 Counseling has taken steps to reduce the risk of spreading the coronavirus. We have posted these efforts on our website and in the office. If you have any questions, please ask.
If you or I are sick
You understand that 20/20 Counseling is committed to keeping everyone safe from the spread of this virus. If you come to an appointment and there is reason to believe that you have a fever or other symptoms, or believe you have been exposed, you will have to to leave the office immediately. We can followup with services by telehealth as appropriate.
If your therapist or any member of the staff at 20/20 tests positive for the coronavirus, you will be notified in order to take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, it may be necessary to notify local health authorities that you have been in the office. If this must be reported, we will provide only the necessary information for data collection and will not provide details as to the reason for your visits. Your signature on this form indicates that no additional signed consent is needed to release this information.
This agreement supplements the general informed consent agreement used at the start of treatment.
Your signature below shows that you agree to these terms and conditions.