• INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

  • This form contains protocols and agreements for meeting in-person. Your signature is required if you would like to opt to return to in-person services. At any point, you may opt to return to a telehealth format. We also may be required to resume that format, depending on the status of the pandemic.

  • Risks of Opting for In-Person Services

  • Although CDC guidelines will be followed, you understand that by coming to the office, there is still a risk of exposure to COVID-19.

  • Your Responsibility to Minimize Your Exposure

  • To obtain services in person, you agree to take certain precautions which will help keep everyone safe.

    • You will only keep your in-person appointment if you are symptom-free, have not tested positive for COVID-19 in the last 30 days or been exposed to someone who has tested positive in the past 14 days.
    • You will wash your hands or use alcohol-based hand sanitizer (provided in the lobby) when you enter the building.
    • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands).
    • You will not bring extra people (i.e. other family members) to your appointment.
    • If you believe you have been exposed to the virus, or are in a high-risk category job such as healthcare, we will cancel the in-person appointment and switch to telehealth.

  • My Commitment to Minimize Exposure

  • My practice has taken the following steps to reduce your risk of exposure:

    • Sanitizing of surfaces after each client
    • Nightly professional cleaning
    • Maintenance of 6 foot distance (easily accomplished in my large office)
    • I will not come to the office if I have any COVID-19 symptoms
    • Waiting room will be open to only one client or couple at a time

    Your signature below shows that you agree to these terms and conditions.

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