INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
You and your therapist 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, your therapist may require that you meet via telehealth. If you have concerns about meeting through telehealth, you and your therapist will talk about it first and try to address any issues. You understand that, if your therapist believes it is necessary, your therapist may determine that you return to telehealth for everyone’s well-being.
*Please note, availability of telehealth services vary by clinician*
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, your
therapist 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 you and your therapist may also need to discuss. Telehealth services are often reimbursed at the same level as face-to-face meetings in the office. You understand that by coming into 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, taxi, or ridesharing service.
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, your therapist, our families, other staff, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in you and your therapist starting/returning to a telehealth arrangement. Initial each statement to indicate that you understand and agree to these actions:
You will only keep your in-person appointment if, to the best of your knowledge, you are symptom free.
- You will allow staff to check your temperature with a no contact thermometer upon entry.
- You will wait outside the clinic until no earlier than 5 minutes before your appointment time.
- You will wash your hands or use alcohol-based hand sanitizer after you enter the building.
- You will adhere to the safe distancing precautions we have set up in the waiting room and therapy rooms. For example, you won’t move chairs or sit where we have signs asking you not to sit.
- You will wear a mask. If you do not have a mask, we will provide you with a mask.
- You will keep a distance of 6 feet from your therapist, staff and others in the clinic. There will be no physical contact (e.g. no shaking hands) with your therapist or staff.
- You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
- If you are bringing your child, you will make sure that your child follows these sanitation and distancing protocols.
- You will take steps between appointments to minimize your exposure to COVID.
- If you have a job that exposes you to other people who are infected, you will immediately let your therapist and our staff know.
- If your commute or responsibilities or activities put you in close contact with others beyond your family, you will let your therapist and our staff know.
- If a resident of your home tests positive for the Coronavirus, you will immediately let your therapist and our staff know. We will then begin or resume treatment via telehealth.
Rainier Behavioral Health may change the above precautions if additional local, state or federal orders or health guidelines are published. If that happens, your therapist will talk with you about any necessary changes.
Rainier Behavioral Health has taken steps to reduce the risk of spreading the Coronavirus within the office and we have posted our ongoing efforts on our website and in the office. Please let your therapist know if you have questions about these efforts.
Your therapist and you understand that we are committed to keeping you, our staff, and all of our families safe from the spread of the virus. If you show up for an appointment, and your therapist, or our office staff believe that you have a fever or other symptoms, or we believe you have been exposed, your therapist will require you to leave the office immediately. Your therapist and you can follow up with services by telehealth as appropriate.
Your Confidentiality in the Case of Infection
If you have tested positive for the Coronavirus, your therapist may be required to notify local health authorities that you have been in the office. If your therapist has to report this, your therapist will only provide the minimum information necessary for the health authority’s data collection and will not go into any details about the reason(s) for your visits.
By signing this form, you are agreeing that your therapist may contact local health authorities without an additional signed release.
This agreement supplements the general informed consent/business agreement that you and your therapist agreed to at the start of your work together.