Dr. Tracy Bennett Psychological Services, Inc.
Tracy Bennett, PhD
Licensed Clinical Psychologist, PSY15696
340 Rosewood Avenue, Suite A
Camarillo, CA 93010
INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS AND/OR FUTURE HEALTH CRISES
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together. This document contains important information about our decision (yours and mine) to schedule in-person services in light of the COVID-19 public health crisis or similar 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.
The Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions, but primarily for sessions with you or your child who requires in-person psychotherapy. If there is a resurgence of the pandemic or if other health concerns arise, however, we may have to reschedule our appointment(s).
Risks of In-Person Services
You understand that by coming to the office, you are assuming the risk for you and your family member of exposure to the coronavirus (or other public health risks). 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, me, 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 our identifying other meeting strategies.
My Commitment to Minimize Exposure
If I test positive for the coronavirus or related illness, I will notify you of your and your child’s possible exposure if we had met previously and upcoming appointments will be rescheduled after I test negative for the virus.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, it is likely that the public health department has been made aware of this. However, if someone who I have worked with or has been seen in the office tests positive, I may be required to provide local health authorities with your contact information. If I have to report this information, 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.
Office Safety Precautions in Effect During the Pandemic
My office is taking the following precautions to protect our clients and help slow the spread of the coronavirus.
Our waiting room is closed.
Office seating in the therapy rooms has been arranged for appropriate physical distancing.
Everyone present wears a mask or face shield.
Everyone present maintains safe distancing.
We maintain a very strong HEPA air purifier and air conditioning.
Restroom soap dispensers are maintained, and everyone is encouraged to wash their hands.
Hand sanitizer that contains at least 60% alcohol is available in the therapy rooms and the waiting room.
We schedule few in-person client appointments per day, with the remaining appointments being offered via telehealth.
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. Trash is disposed of on a frequent basis.
Therapy rooms are thoroughly disinfected at the beginning and end of each session.