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, I may require that we meet via Telehealth. If you have concerns about meeting through Telehealth, we will talk about it and address any issues you have. You understand that, if I believe it is necessary, I 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. Reimbursement for Telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss if it arises.
Risks of Opting for In-Person Services
You understand that, by coming into the office, you are assuming the risk of possible exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or a ride sharing 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, our families, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting/ returning to a Telehealth arrangement. Please check the box next to each statement below to indicate that you understand and agree to these actions: