By setting appointments to being seen in person and signing this document, you agree that:
You acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
You acknowledge that there is an increased risk of hospitalization and severe symptoms if you are unvaccinated and contract COVID-19.
If you are unvaccinated, it is requested for you to share this information with your therapist so your therapist can make an informed decision about the risk to themselves and other clients and the precautions they must take. You also understand that if you are unvaccinated, your therapist has the right to decide whether or not in-person sessions are safe or feasible at this time.
Your health is very important to us. In addition to your health, the guidelines we have set related to COVID-19 are to protect ourselves, our families and communities, and our other clients as well. We cannot do our best work if we feel our health and safety are not being respected as well.
You understand that it must be explicitly discussed that your session is an in-person session. Unless you and your therapist have planned for a specific session or all of your sessions to be in person, your session will be a telehealth session. Please reach out to your therapist if you are unsure if your session is to be in person or over telehealth.
Similarly to if you are having symptoms, if your therapist is having any symptoms they will also not be able to meet in person. In this case, if your therapist is well enough, you will be given the option to have a telehealth session or reschedule
You voluntarily seek services provided by Mantra Mental Health, LLC and acknowledge that you are increasing your risk of exposure to the Coronavirus/COVID-19. You acknowledge that you must comply with all set procedures to reduce the spread while attending your appointment.
You understand that future in-person sessions are not guaranteed and are dependent on safety recommendations and guidelines by Mantra Mental Health, LLC's owner, Samantha Bergstein’s ethical board, legal recommendations, local, state, and national health professionals, and Mantra Mental Health, LLC clinicians’ professional and personal needs.
You further acknowledge that Mantra Mental Health, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19 including efforts to disinfect space, reduce the number of people in the building and office, increased time between sessions as means of allowing the office to ventilate, and you agree to the following safety precautions for all clients including:
Let your therapist know by phone or email if you are not feeling well or are uncomfortable with an in-person session at any time. We can have a telehealth/phone session instead if needed. Requests to see your therapist via telehealth instead of in-person will NOT result in a cancellation fee. Please let your therapist know as soon as possible if you would prefer a telehealth session.
You agree that you will only enter the building or allow your therapist to enter your home (if your session is an in-home visit) if:
You are not experiencing any symptoms of illness such as, but not limited to: cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
You have not traveled internationally or to highly impacted areas within the United stated within the past 14 days.
You do not believe you have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19 within the past 14 days.
You have not recently been diagnosed with COVID 19.
If your session is in-office, once you get to the building:
You agree to wear a mask while in the building and in the therapist's office and sanitize/wash your hands after using the restroom.
You agree to maintain 6 feet of space between yourself and your Mantra Mental Health, LLC therapist and any individuals you may encounter in the building.
You agree to have your temperature taken before your session if it is recommended by health officials at the time of our session.
You agree to other COVID-related requests that your therapist may make to protect you and themselves when entering your home or scheduling in-home visits.
You will wait for the therapist in the 3rd floor “Suite 300 waiting area”
If your session is in-home:
You agree to wear a mask while the therapist is present in your home and sanitize/wash your hands after using the restroom.
You agree to maintain 6 feet of space between yourself and your Mantra Mental Health, LLC therapist.
You agree to have your temperature taken before your session if it is recommended by health officials at the time of our session.
You agree to other COVID-related requests that your therapist may make to protect you and themselves when entering your home or scheduling in-home visits.
Similarly to if you are having symptoms, if your therapist is having any symptoms they will also not be able to meet in person. In this case, if your therapist is well enough, you will be given the option to have a telehealth session or reschedule
Cancellation Policy- by signing this document you agree that you understand:
The fee for a late cancellation (canceling less than 24 hours before a telehealth session and less than 72 hours for an in-person session) is $50 unless you have Medicaid.
You will be charged the full fee of your session for a “no show” (not showing to a telehealth or in-person session as scheduled and not calling ahead of time to cancel. Your session is considered a no-show if you're 30 or more minutes late to your session) unless you have Medicaid.
Although there is a window for cancellation that will prevent you from having to pay the late cancellation or “no-show” fee, if you are frequently canceling appointments this can impact the ability for us to make therapeutic progress and also may make it difficult for other clients who need to be seen be scheduled in a timely manner. Thus, if the 24-hour or 72-hour cancellation policy is used very frequently, it may be required for us to problem-solve in order to reduce overall cancellations. Excessive cancellations, even within the 24-hour period, may result in termination of services if a solution cannot be reached.
If you “no show” (don’t show for your appointment and don’t call or email me to notify me that you cannot make your appointment), all appointments after this date may be canceled and will need to be rescheduled. It cannot be guaranteed that your original appointment time will still be available. Please notify your therapist as soon as possible if you are unable to make an appointment.
Frequently canceled in-person sessions may result in the requirement for you to participate in telehealth-only services for a period of time due to the limited availability of in-person sessions.
You further acknowledge that Mantra Mental Health LLC cannot guarantee that you will not become infected with the Coronavirus/Covid-19. You agree to release and hot hold Mantra Mental Health, LLC responsible if you contract COVID-19 including any future COVID-19 strains that may develop. You understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of yourself and others, including, but not limited to, Mantra Mental Health staff, and other Mantra Mental Health clients and their families. You understand that failure to follow these guidelines may result in the loss of access to scheduling in-person sessions and may have a serious impact on your therapist's and other clients' well-being.