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.

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

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 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.