Informed Consent for In-Person Services

Decision to Meet In Person

I consent to meeting in person with my therapist Anne G. Walker LCSW. If there is a resurgence of the pandemic or if other concerns arise my therapist may require that we meet via telemental health. Should I be unable to participate in telemental health I will notify my therapist of barriers and we will create a plan for care.

I may voluntarily request telemental health services at any time. My therapist will advise on clinical appropriateness related to my care. Additionally I am aware there may be reimbursement limitations as determined by my health insurance carrier.

Risks of Opting for In-Person Services

I understand that by presenting to my therapist's office I am assuming the risk of exposure to the coronavirus or any other public health risk.

My Responsibilty to Minimize Exposure

To obtain services in person, I agree to taking certain precautions which helps reduce risk to myself, my therapist, related office staff, and other clients receiving care. Should I be unable to adhere to these standards I agree to notify my therapist and discuss care plans which may include virtual sessions.

I will attend my in-person session only if I am symptom free.

I agree

I will take my temperature prior to each appointment and if elevated above 100 degrees (or if I have any other symptoms) will cancel and participate via telemental health if able. A late cancellation fee will not be charged.

I agree

I will wait in my car or outside until no earlier than 5 minutes prior to my appointment time. I will not have any additional persons in the waiting area unless preauthorized by my therapist. I will adhere to safe distancing practices in the waiting area, including not moving chairs.

I agree

I will disinfect my hands upon entering the office with provided alcohol-based sanitizer.

I agree

I will wear a mask in all areas of the office, as will my therapist and staff.

I agree

I will take steps between sessions to minimize exposure. I will notify my therapist of any close contact I have had with someone testing positive for COVID-19 prior to my appointment.

I agree

Office Commitment to Minimizing Exposure

I understand that my therapist has made every effort to provide a healthy and safe environment for her clients, including use of alcohol based hand sanitizer, social distancing, mandated mask wearing, and requiring all age or health eligible clients to be vaccinated for COVID-19 for in-person sessions. My therapist may be required to notify public health authorities should a positive case has presented in her office. Only minimal information that is necessary for case tracking and data collecting will be provided.

This agreement supplements the general informed consent that was signed at the initiation of care. My signature confirms my agreement to these terms and conditions.

Signature

Name

First NameLast Name

Date

Informed Consent for In-Person Services during COVID-19 Public Health Crisis