- INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about you and your therapist’s decision to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully, and let your therapist know if you have any questions.
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, your therapist and CenterLife Counseling may require that the sessions occur via telehealth. You understand that, if your therapist and CenterLife Counseling believe it is necessary, we may determine that we return to telehealth sessions for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, your therapist and CenterLife Counseling 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. Consistent with the Clinic Policies of CenterLife Counseling, you are responsible for reimbursement if CenterLife Counseling is not able to obtain reimbursement through insurance, including for reasons related to the provision of telehealth services.
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, your therapist, office staff and our families, and other clients) safer from exposure, sickness, and possible death. If you do not adhere to these safeguards, it may result in you and your therapist starting or returning to a telehealth arrangement. In order to return to in-person sessions at CenterLife Counseling, we need you to do the following:
- Only keep your in-person appointment if you are symptom free. Call to switch your session to a Telehealth appointment if you have symptoms.
- Take your temperature before coming to each appointment. If it is elevated (100 degrees Fahrenheit or more), or if you have other symptoms of the coronavirus or Covid-19, you agree to change your appointment to telehealth.
- Wait in your car or outside of the office until no earlier than 5 minutes before your appointment time.
- You and your therapist will need to wear a mask at all times while in session and in the office building.
- Wash your hands or use alcohol-based hand sanitizer when you arrive at our office for your appointment. There is a hand sanitizer dispenser in the waiting room.
- Adhere to any safe distancing precautions we have set up in the waiting room and therapy room. For example, you will not move chairs or sit where we have signs asking you not to sit.
- Keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with CenterLife staff and therapist.
- 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 for a session, make sure that your child follows all of these sanitation and distancing protocols.
- Only the client having a session is allowed into the office building, so do not bring other family members or pets with you to your sessions.
- Take steps between appointments to minimize your exposure to COVID-19 (practice social distancing and wear protective items when in public).
- If you have a job that exposes you to other people who are infected, let CenterLife staff and therapist know.
- If your commute or other responsibilities or activities put you in close contact with others (beyond your family), let CenterLife staff and therapist know.
- If you test positive for the coronavirus, or are directly exposed to someone who is, let CenterLife staff and therapist know as soon as possible.
CenterLife Counseling and your therapist may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, your therapist will inform you about any necessary changes.
Commitment to Minimize Exposure
CenterLife Counseling and your therapist have 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. These are provided at the end of this document. Please let your therapist know if you have questions about these efforts.
If You or Your Therapist Are Sick
You understand that your therapist and CenterLife Counseling is committed to keeping you, therapists, office staff, our families, and communities safe from the spread of this virus. When you arrive for an appointment, either your therapist or office staff will take your temperature, and if it is elevated (100 degrees Fahrenheit or more), we will require you to leave the office immediately. We can follow up with services by telehealth as appropriate.
Likewise, if your therapist tests positive for the coronavirus, or has been directly exposed to someone who has tested positive, your therapist will notify you so that you can take appropriate precautions, including a return to telehealth delivery of services.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, your therapist or CenterLife Counseling may be required to notify local health authorities that you have been in the office. If required to report, only legally required information will be provided. No details regarding the reason(s) for your sessions at CenterLife will be provided. By signing this form, you are agreeing that they may do so without an additional signed release.
This agreement supplements the general informed consent/clinic policies that was agreed to at the start of your work with your therapist at CenterLife Counseling.
Your signature below indicates that you agree to these terms and conditions.
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Office Safety Precautions in Effect During the Pandemic
CenterLife Counseling is taking the following precautions to protect our patients and help slow the spread of the coronavirus.
- Office seating in the lobby has been arranged for appropriate physical distancing to the extent practical and feasible.
- No touch temperature checks given to all staff, therapists, and clients.
- Therapists and office staff will wear a mask and require that clients do the same.
- We will take reasonable steps to ensure safe distancing.
- Hand sanitizer that contains at least 60% alcohol is available in the office.
- We ask all patients to wait in their cars or outside the office 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.
- Common areas in and around the office are wiped down and disinfected throughout the day.
- Magazines, coffee, tea and water dispenser will not be available.