INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19
This document contains important information about our decision (yours and your Brave Soul Counseling clinician) to resume in-person services in light of the COVID-19 global pandemic. It is important you are aware of measures Brave Soul Counseling Services (Brave Soul) is taking to help ensure the safety of clients and its clinicians. You are aware that you must follow the guidelines set forth below and also are aware that you will be assuming all health risks potentially associated with being seen in person at our office.
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, however, I may require that we meet via telemedicine. You understand that, if I believe it is necessary, I may determine a return to telemedicine for everyone’s well-being. If you decide at any time that you would feel safer staying with, or returning to, telemedicine services, I will respect that decision, as long as it is feasible and clinically appropriate.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to COVID-19 (or other public health risk). Clients must not come into the office if they themselves or someone in their family has tested positive for COVID-19.
Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, other clinicians and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telemedicine arrangement.
- You will only keep your in-person appointment if you are symptom free.
- Clinicians have the right to briefly screen how the client is feeling prior to the session beginning, including taking a client’s temperature with a touch-free infrared forehead thermometer. If a client has a fever or is not feeling well, the clinician may ask the client to leave and reschedule the session.
- You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of COVID-19, you agree to cancel the appointment or proceed using telemedicine. If you wish to cancel for this reason, I won’t charge you our normal cancellation fee.
- No additional family members may come to the appointment unless specifically asked to do so by your clinician.
- You will wash your hands or use alcohol-based hand sanitizer before entering your therapy session.
- You will adhere to the safe distancing precautions we have set up in the waiting room and therapy room.
- You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me.
- You will take steps between appointments to minimize your exposure to COVID-19.
- If you have a job that exposes you to other people who are infected, you will immediately let me know.
- If a resident of your home tests positive for COVID-19, you will immediately let me know and we will then begin or resume therapy via telemedicine.
Brave Soul may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
Our Commitment to Minimize Exposure
Brave Soul has taken steps to reduce the risk of spreading COVID-19 within the office, including extra measures to increase cleanliness of the office spaces. These cleaning practices follow the CDC cleaning guidelines. Please let us know if you have questions about these efforts.
If I or any other clinician at Brave Soul test positive for COVID-19, I will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for COVID-19, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
Informed Consent
This agreement supplements the general informed consent that we agreed to at the start of our work together.
Your signature below shows that you agree to these terms and conditions.
