INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19
At the Center for Counseling Arts we are committed to the highest quality of care. This agreement contains important information about the decision to accept in-person services during the novel Coronavirus / COVID-19 public health crisis. Please read carefully. The Decision to Accept In-Person Services & Rapidly Changing Events We are agreeing to in-person services at the time scheduled with you. However, at the event of a resurgence of the pandemic or other health concerns, we may require a return to virtual telehealth sessions and /or the immediate cancellation of your appointment. We will do our best to answer any concerns you may have regarding this change, but the decision may rest exclusively at the discretion of the Center for Counseling Arts and /or your individual therapist, for everyone’s well-being. If at any time you would feel safer returning to telehealth services, we will respect this decision and try to accommodate, as long as telehealth services are feasible and clinically appropriate. Reimbursement for telehealth services is also determined by the insurance companies and applicable law; if telehealth is no longer accepted by insurance companies, we may be unable to resume this format. Our Commitment to Minimize Potential Exposure We at the Center for Counseling Arts and your individual therapist will do our best to follow the safety procedures and guidelines offered by the CDC, EPA, APA and related professional bodies to reduce the chances for exposure to the virus that causes COVID-19. These precautions include: • Office seating arranged for appropriate physical distancing. • Masks worn and available when required and appropriate. • Staff instructed to maintain safe distancing. • Hand sanitizers and soap dispensers readily available and maintained. • Staggered appointments at specific intervals to minimize unnecessary contact. • Clients requested to wait in cars or outside when possible, and by mobile phone to check-in with staff before entering. • Frequently touched surfaces routinely sanitized. • Tissues and trash bins easily accessed; refuse disposed on a frequent basis. • Common areas thoroughly disinfected at the end of each day. The Risks of Opting for In-Person Services You agree that by coming to the office, you are assuming the risks of exposure to the coronavirus or other public health risks. These risks may increase if you travel by public transportation, cab, or ridesharing service. Your Responsibility to Minimize Potential Exposure To obtain in-person services, you agree to each of the following precautions for the safety of everyone. If you do not adhere to these safeguards, we may start / return to a telehealth arrangement. • You will only keep an in-person appointment if you are symptom-free. If you notice potential symptoms of the coronavirus - an elevated temperature of over 100 °F, chills, congestion or runny nose, cough, headache, fatigue, muscle ache, new loss of smell or taste, sore throat, trouble breathing or shortness of breath, gastrointestinal problems such as nausea, vomiting, abdominal pain or diarrhea - you agree to cancel the appointment and to proceed using telehealth if possible. All short-notice cancellation fees are waived at this time, and we would much rather you stay home and stay safe. • If a resident of your home tests positive for the infection, you will inform the Center for Counseling Arts and / or your individual therapist; we will instead begin or resume treatment via telehealth, if possible. • If you have a job, responsibilities or activities that expose you to other people who are infected, you will inform the Center for Counseling Arts and /or your individual therapist. • You will not bring any unnecessary accompanying visitors. If you are bringing your child, please do your best to ensure your child follows sanitation and distancing protocols. • At your arrival you will wait in your car or outside, if possible, and phone or text your therapist or our staff. You will continue to wait, if possible, until you receive a call or text welcoming you inside. • Before your session you will wash your hands or use alcohol-based hand sanitizer provided by us. • You will allow your therapist to ask essential questions about potential symptoms, and to take your temperature via a touch-free infrared thermometer if appropriate or recommended by professional agencies. • During your session you will adhere to safe distancing precautions, trying to maintain 6 feet from staff, your therapist and other potential clients. • You will wear a mask in all areas of the office if required or recommended by state or federal guidelines. • You will please try to avoid touching your face with your hands. If you do, you will immediately wash or sanitize your hands. We may change the above precautions if additional local, state or federal orders or guidelines are published. We will discuss these changes with you. If You Are Sick We are committed to keeping you, our staff and all of our families safe from the spread of this virus. If, at the time of your appointment, you show symptoms of concern, or we believe you may have potentially been exposed, you are required to leave the office immediately. We will follow-up up with services by telehealth if possible. Your Confidentiality in the Case of Infection If you have tested positive for the coronavirus, we may be required to notify local health authorities that you have been in the office. We will only provide the minimum information necessary for their data collection and we will not provide any of the reason(s) for our visits. By signing this form, you are agreeing that we may do so without an additional signed release. Informed Consent This agreement supplements our general informed consent and other professional agreements; those other agreements are still active and in place. Your signature below shows that you understand and agree to these terms and conditions.
Your Full Name
- Select -
Harlee Abromson, LCSW
Matthew Adams, LPC
Marisa Costa, MET, LPC
George Dalzell, LCSW
Nicholas Demaio, LPC
Dr. Megan Dufford, PsyD
Katelyn Elliot, NCC, LPC
Adria A. Fredericks, MEd, LPC
Dr. Nancy Lardo, PhD
Jinna Leo, MEd, LPC
Debi Lyons Genovesi, LCSW
Lindsay Pierce, MAAT, LPC
If your therapist is not listed above, please enter his / her / their name here:
Would you like the Center to reach out to you for further discussion regarding the new procedures?
No, I do not have any questions regarding the new procedures.
Yes, I would like to speak to someone at the Center to further discuss the new procedures.
What preferred number would you like us to call if needed?
Best times to call:
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