INFORMED CONSENT FOR IN-PERSON SERVICES DURING THE 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 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

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 video conference or over the phone. If you have concerns about meeting through these means, 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 video and audio based sessions for everyone’s well-being. 

 

If you decide at any time that you would feel safer staying with, or returning to, the above session formats, I will respect that decision, as long as it is feasible and appropriate. Reimbursement/credit/etc. for pre-paid services in the case of a sudden change of how we choose the interface of our sessions, however, is an issue we may also need to discuss. 

 

Risks of Opting for In-Person Services

You understand that by coming to this rental space, 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, other staff and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a virtual session 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 and/or  you will allow me to take your temperature with a forehead thermometer. 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 virtual means.  If you wish to cancel for this reason, I won’t charge you a cancellation fee, but because you reserved my time and the room you will be charged for a portion of the session. __

  • You will arrive at your appointment time and no time before then in order to keep you from crossing paths with others. ___

  • 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 agreed upon during our negotiation. ___

  • You will wear a mask in all areas of the building (I will too). ___

  • You will do your best to keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands, hugging) 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. ___

  • 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 colleagues] 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 colleagues] know and we will then begin/resume virtual sessions if we agree to more sessions.___

 

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 rental space has taken steps to reduce the risk of spreading the coronavirus within the rental space and I have posted our efforts on my website. 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 colleagues] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my colleagues] 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 video call or phone call as appropriate.

 

If I [or my colleagues] test positive for the coronavirus, I will notify you so that you can take appropriate precautions. 


 

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

 

_________________________ _________________________

Practitioner                                Date


 

Precautions in Effect During the Pandemic:


 

My in-call space is taking the following precautions to protect our clients and help slow the spread of the coronavirus.

 

  • Strict social and physical distancing measures including minimizing time in waiting areas and maintaining low in-space client volumes;

  • Universal screening of all clients based on symptoms and using thermometers;

  • Rigorous cleaning and disinfecting, concentrating on high traffic areas, frequently touched surfaces, and play rooms;

  • Refining my list of provided activities;

  • Mandating a mask or face covering for all clients at all times while in the facilities, in accordance with CDC recommendations.

  • Continuing to stay up to date on the standard of care with regards to testing.

  • Seating in the waiting room, if offered, has been arranged for appropriate physical distancing. 

  • My colleagues and I wear masks.

  • My colleagues maintain safe distancing, in fact, you will most likely never see anyone but me.

  • Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.

  • Hand sanitizer that contains at least 60% alcohol is available in the waiting room and stronger sanitizer in the session rooms.

  • We schedule appointments at specific intervals to minimize the number of people who may cross paths. It is incredibly rare that you will ever come into contact with someone other than myself.

  • We ask all clients to arrive at their appointment times.

  • Physical contact is not permitted until after negotiation.

  • Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.

  • Common areas are thoroughly disinfected at the beginning and end of each day, as well as every time they are used.