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