Please click on the link above for a PDF copy of the 

Informed Consent form for In-Person Services During COVID-19 Public Health Crisis.

It's printed below as well.

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 considering the COVID-19 public health crisis. 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   Not Applicable

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, however, I may require that we

meet 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 feel safer staying with, or returning to, telehealth

services, I will respect that decision, as long as it is feasible and clinically appropriate.

Reimbursement for telehealth services, however, is also determined by the insurance

companies and applicable law, so that is an issue we may also need to discuss.

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 (you, me, and our families, [my other staff] and other patients) safer from exposure,

sickness and possible death. If you do not adhere to these safeguards, it may result in our

starting / returning to a telehealth arrangement. Initial each to indicate that you understand and

agree to these actions:

● 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 wish to cancel for this

reason, I won’t charge you our normal cancellation fee.

● You will wait in your car or outside [or in a designated safer waiting area] until no earlier

than 5 minutes before our appointment time.

● You will wash your hands or use alcohol-based hand sanitizer when you enter the

building.

● You 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 will keep a distance of 6 feet and there will be no physical contact. (e.g. no shaking

hands) with me [or staff].

● You will try not to touch your face or eyes with your hands. If you do, you will

immediately wash or sanitize your hands.

● If you are bringing your child, you will make sure that your child follows all of these

sanitation and distancing protocols.

● You will take steps between appointments to minimize your exposure to COVID.

● If you have a job that exposes you to other people who are infected, you will immediately

let me [and my staff] know.

● If your commute or other responsibilities or activities put you in close contact with others

(beyond your family), you will let me [and my staff] know.

● If a resident of your home tests positive for the infection, you will immediately let me [and

my staff] know and we will then [begin] resume treatment via telehealth._

I may change the above precautions if additional guidelines are published. If that happens, we

will talk about any necessary changes.

My Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the

office and we have posted our efforts on our website and in the office. Please let me know if you

have questions about these efforts.

If You or I Are Sick

You understand that I am committed to keeping you, me, [my staff] and all of our families

safe from the spread of this virus. If you show up for an appointment and I [or my office staff]

believe that you have a fever or other symptoms, or believe you have been exposed, I will have

to require you to leave the office immediately. We can follow up with services by telehealth as

appropriate.

If I [or my staff] test positive for the coronavirus, I will notify you so that you can take

appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health

authorities that you have been in the office. If I must 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.

Informed Consent

This agreement supplements the general informed consent/business agreement that we

agreed to at the start of our work together. Your signature below shows that you agree to these

terms and conditions.

Client Date___________________

Counsellor Date __________________