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

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
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
We have agreed 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, in my sole discretion, 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. Insurance reimbursement for telehealth services, however, is determined by the insurance companies and applicable law—that is in the event your insurance refuses to pay fully or decides to only pay partially for the telehealth sessions, it is your responsibility to pay the balance.
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-Covid19 (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 which will help keep everyone (you, me, and our families, PeoplePsych staff and other clients) safer from exposure, sickness and possible death. If you do not consistently adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.
Initial each item to indicate that you understand and agree to these actions:
You will only keep your in person appointment if you are symptom free.*
You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I won’t charge you our normal cancellation fee.*
Only the person with the appointment will come to the session and be admitted to the suite.*
You will wait outside of the building until no earlier than 5 minutes before our appointment time.*
You will use alcohol-based hand sanitizer when you enter the suite.*
You will adhere to the safe distancing precautions we have set up.*
You will wear a mask in all areas of the building and understand that I will as well.*
You will keep a distance of 6 feet and there will be no physical contact between us including no handshakes or other greeting.*
You will try not to touch your face or eyes with your hands. If you do, you will sanitize your hands.*
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 know.*
If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know.*
a resident of your home or person with whom you have had close contact tests positive for the infection, you will immediately let me know and we will switch to conducting sessions via telehealth for a minimum of 2 weeks.*
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, my colleagues and the larger community safe from the spread of this virus. If you show up for an appointment and I believe that you have symptoms of any virus, or believe you have been exposed to the coronavirus, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

If I or anyone with access to the office test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
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.

Your signature below shows that you agree to these terms and conditions.
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INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

Decision to Meet Face-to-Face

Risks of Opting for In-Person Services

Your Responsibility to Minimize Your Exposure

Initial each item to indicate that you understand and agree to these actions:

My Commitment to Minimize Exposure

If You or I Are Sick

Your Confidentiality in the Case of Infection

Informed Consent