Informed Consent for Returning to In-Person Services

This Consent for Returning to In-Person services is a supplement to our Outpatient Services Contract that we agreed to at the outset of our clinical work together.

As a way to mitigate the ongoing risk of exposure to COVID-19, our practice has transitioned to providing most services via telehealth. Telehealth services reduce the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, telehealth services may not be adequate, and in-person services may be more appropriate.

The decision about whether to engage in in-person services is based on current conditions and guidelines, which may change at any time. It is possible that a return to remote services will be necessary at some point based on consideration of health and safety issues. Such a decision will be made in consultation with you, but I will make the final determination based on a careful weighing of the risks and applicable regulations.

It is also important to consider that, although insurance reimbursement for telehealth services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect, and telehealth services may no longer be reimbursed by your insurance company. You will be responsible for checking this coverage prior to services.

In order for us to provide you with in-person services, the following protocols must be followed by patients/clients and providers:

  • Social distancing requirements must be met, meaning that you must maintain a six-foot distance from others while in offices, waiting rooms, and other areas. There will be no physical contact with others in the office.
  • You must complete our online Health-Screening Questionnaire on the day of your appointment.
  • Clients and providers will be required to wear face coverings or masks while in the office. If you do not have a face covering, you may purchase one for $2.00 from us.
  • Hand sanitizer will be provided at the office entrance and must be used upon entering the office.
  • You will be asked to wait in your vehicle or outside the office until you receive a text, email, or phone call from office staff indicating that you can enter the office.
  • You agree not to present for in-person services if you have a fever, shortness of breath, coughing, or any other symptoms associated with COVID-19 or if you have been exposed to another person who is showing signs of infection or has confirmed COVID-19 within the past two weeks. Our typical cancellation policy applies.
  • If you are bringing a child/dependent in for services, you agree to ensure that both you and your child/dependent follow all of these protocols.

As COVID-19 regulations continue to evolve, I may become legally required at some point to disclose that you and I have been in contact, especially if either of us were to test positive or show signs of COVID-19 infection. If I am legally compelled to disclose information, I will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law.

We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know.

By signing below, you acknowledge that you understand that there is still a risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services.

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