12. Consent for In-Person Services During Covid-19 Public Health Crisis
This form contains important information about our decision to conduct in-person services regarding the COVID-19 public health crisis and to set expectations surrounding some corresponding changes to facilitate health safety for our meetings. Please read this carefully and share any questions you have before signing this document, as it will be an official agreement between us.
Decision to Meet in Person:We have agreed to meet in person for some or all future sessions. Please understand that if there are any future state emergency limits, shelter in place orders or illness impacting our ability to meet, we will develop a reasonable plan to reschedule or meet using tele-mental health or alternative communication resources that meet the confidentiality requirements necessary to work together. If you decide at any time that you are comfortable moving or returning to tele-mental health services, we will outline the plan and confirm that the communication method is clinically appropriate.
Risks of Opting for In-Person Services:Please understand that by coming to the office, and/or meeting for such services in any other venue, you are assuming the risk of exposure to the coronavirus for yourself and/or child (or any other public health risk); and you agree to waive all rights and claims against my practice and me both jointly and severally for damages arising therefrom. This risk may increase if you travel by public transportation, cab, or ridesharing service.
Practice Steps to Reduce Exposure:My practice has taken steps to reduce the risk of spreading the coronavirus within the office. I am following the guidelines outlined by the CDC and LARA (the licensing and regulatory board of Michigan) to improve safety from virus contagion. Please note that because I sometimes work with children, some regulations around social distancing and wearing a mask may be more difficult to stringently implement as children are less likely to understand and adhere to this throughout our session. I will wear a mask during sessions and attempt to follow social distancing recommendations until there is evidence to suggest that a mask or social distancing is no longer needed. If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions as you deem necessary. Although these steps will improve safety, it is impossible to guarantee any outcome with an invisible virus. Please let me know if you have questions about these efforts. It is my duty to inform you that the CDC and LARA recommend that a mask or face covering be worn throughout health care appointments.
By signing this form, you agree to adhere to each of the following:
Client Name: Client Email:
Minor Name (if also applicable): Client Relationship to Minor (if also applicable):
Leave this empty:
Your legal name
Your email address
Signed by Jordana Wolfson
Signed On: February 17, 2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: 12. Consent for In-Person Services During Covid-19 Public Health Crisis
Agree & Sign