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Covid – Client Agreement

  • INFORMED CONSENT FOR IN-PERSON MENTAL HEALTH SERVICES DURING COVID-19 PANDEMIC

    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. Our decision is based in part on recommendations by the Centers for Disease Control (CDC), but other factors may be considered. Some of these include but are not limited to the following: 1) whether we and our families have been vaccinated, 2) our health or the health of those with whom we are in close contact, and 3) risk of exposure outside of this setting. There may be other concerns that we can discuss.

    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. 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 is also determined by the insurance companies and applicable law, so you will be financially responsible for telehealth services not covered by your insurance company.
  • RISK OF OPTING FOR IN-PERSON SERVICES

    You understand that by coming to my office, you are assuming the risk of exposure to the coronavirus (or other public health risk).
  • YOUR RESPONSIBILITY TO MINIMIZE YOUR EXPOSURE

    To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, your family, other therapists, and other patients) safe from exposure, sickness, and possible death. If you do not adhere to these safeguards, it may result in our returning to telehealth services. Please review each action item below and let me know if you have any question. Your signature on this document indicates agreement with these action items.

    You (and your significant other) will:
    • Only keep your in-person appointment if you and your significant other are symptom free
    • Agree to cancel the in-person appointment if you or your significant other have symptoms of the coronavirus.
    • Cancel your appointment if you have been in contact with someone who has tested positive within the last 14 days
    • Wash your hands and/or use alcohol-based hand sanitizer when you enter the office and on a regular basis over the course of the session
    • Wait in the car until you are called in for your appointment, as the waiting room is closed
    • Wear a mask upon entering the building and office. Wearing a mask is optional during the session; however, I may choose to wear a mask
    • Maintain a distance of 6 feet along with no physical contact (e.g., no shaking of hands)
    • Take steps between appointments to minimize exposure to the coronavirus
    • Immediately inform me should you have or take a job that exposes you to other people who are infected (or you become aware of exposure)
    • Immediately inform me if you have been in close contact with others (beyond your family)
    • Immediately inform me if a resident of your home tests positive for the infection. We will then consider the use of telehealth options.
    JAC may change the above precautions if additional local, state, or federal orders or guidelines are published. If that occurs, we will discuss any necessary changes.

    JAC has taken steps to reduce the risk of spreading the coronavirus within the office. Please let me know if you have questions about these efforts.

    If I or anyone close to me tests positive for the coronavirus, I will notify you so that you can take appropriate precautions.

    If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If reporting is required, 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 visit. 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 agreement that we executed at the start of our work together.

    Your signature below indicates that you agree to these terms and conditions.
  • Date Format: DD slash MM slash YYYY