CONSENT IN-PERSON SERVICES

Informed Consent for In-person Services During COVID-19 Public Health Crisis

This document contains important information about our decision to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let us know if you have any questions. When you sign this document, it will be an official agreement between you (the client) and the therapists (staff) at Best Practice Psychotherapy.

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, we may require sessions be conducted 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 we believe it is necessary, we 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, we will respect that decision, if 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 (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 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, we won’t charge you the normal cancellation fee.

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

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

If you are bringing your child, you will make sure that your child follows all these sanitation and distancing protocols.

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 adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.

You will be asked to wear a mask in all areas of the office (staff will do the same).

If you have a job that exposes you to other people who are infected, you will immediately let your therapist know.

If a resident in your home tests positive for the infection, you will immediately let your therapist know and you will be asked to resume treatment via telehealth platform, Doxy.me.

If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let your therapist know.

We will change precautions if additional local, state, or federal orders or guidelines are published.
If that happens, we will talk about any necessary changes.

Best Practice Psychotherapy Commitment to Minimize Exposure

Our 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 we are committed to keeping you, our staff, and all our families safe from the spread of this virus. If you show up for an appointment and you are visibly sick, we will ask that you leave the office immediately. We can follow up with services by telehealth as appropriate.

If a staff member tests positive for the coronavirus, you will be notified so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, staff may be required to notify local health authorities that you have been in the office. If we must report this, we 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 we 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 Signature

Mental Health Therapist

I have read, understand, and agree with the Best Practice Psychotherapy Informed Consent for In-person Services During COVID-19.

Thanks for submitting!

My office is taking the following precautions to protect our patients and help slow the spread of the coronavirus.

Office seating in the waiting room and in therapy/testing rooms has been arranged for appropriate physical distancing.
My staff and I wear masks.
My staff maintains safe distancing.
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 therapy/testing rooms, the waiting room and at the reception counter.
We schedule appointments at specific intervals to minimize the number of people in the waiting room.
We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.
Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized after each use.
Physical contact is not permitted.
Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
Common areas are thoroughly disinfected at the end of each day.