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

 

Decision to Meet Face-to-Face

I, as your therapist, and you agree 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, I may require that we meet 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 I believe it is necessary, I 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, I 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, 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 that will mitigate the risk to everyone (you, me, our families, our staff and other clients) 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.  

• You will only keep your in-person appointment if you are symptom free. Symptoms include fever, cough, shortness of breath, chills, muscle pain, sore throat, new loss of taste or smell, cold or flu, nasal congestion or runny nose, extreme fatigue, vomiting or diarrhea. Emergency warning signs that require medical attention immediately: trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, bluish lips or face.  You will take your temperature before coming to each appointment. If it is elevated (100ᵒ Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. You will not be charged a cancellation fee due to illness.

• If you have been out of the state or country, you will not schedule an in-person session for 10 days after your return or you will bring the negative test results of a COVID-19 test taken after your return.

• You will wait in your car or outside (maintaining 6 feet of social distancing from others) until your therapist comes to the front door to the parking lot.

• You will follow me directly to the office we will use. I will open/close doors if necessary.

• 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 wear a mask as you come into the Center's office building and while in the hallways. Once in my office, you and I can decide to wear masks or not.

• You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with staff or me.

• You will take steps between appointments to minimize your exposure to COVID-19.

• If you have a job that exposes you to other people who are infected, you will immediately let me and our staff know.

• If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me and our staff know.

• If a resident of your home tests positive for the infection, you will immediately let me and our staff know and we will then begin or resume treatment via telehealth.

• To minimize risk of spreading germs during this time, we will not offer any beverage. Should you need to have something to drink during our session, please bring the beverage with you and bring the bottle or cup back out with you. There is a garbage bin just outside the front door.

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

My Commitment to Minimize Exposure

My 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 I am committed to keeping you, me, our staff and all of our families safe from the spread of this virus. If you show up for an appointment and I or our Pastoral Counseling Center staff believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

If our staff or I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

 

Insurance Considerations

Although insurance reimbursement for teletherapy services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect. You may want to check your insurance plan to determine if your co-pay will be different for in-person therapy.

 

Your Confidentiality in the Case of Infection

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

 

Please sign below to indicate you understand and agree to these safety precautions.

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