COVID-19 informed consent for in person sessions
None

Has anyone created or found a good template for an informed consent for therapists who will be resuming in person sessions during the COVID-19 pandemic? For clients to sign that they understand the risks, as well as the precautions and policies for safety, and that they have the choice to choose between in person and Telehealth? 

Thanks! 

9 comments

  • 4
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    Heather Dick

    I created one based on a few different ones I reviewed. I don't know how to attach it so I have copied/pasted below for you.

    INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

    * This agreement is between Mana Life Counseling (formerly Heather D Counseling) and
    First and Last Name
    * Date

    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.

    In accordance with local guidelines for the COVID-19 public health crisis, Mana Life Counseling LLC will resume in-person services as of June 1, 2020. If the pandemic or other concerns resurface, you may be required to return to telehealth-only services out of an abundance of caution for everyone’s safety.

    By signing this agreement you acknowledge that you have voluntarily sought in person services and acknowledge that you are increasing your risk of to exposure to the Coronavirus/COVID-19. You acknowledge that you must comply with all set procedures to reduce the spread while attending your appointment.

    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 potential exposure. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.

    If, at any time, you decide 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 determined by the insurance companies and applicable law and is subject to change depending on applicable laws and insurance regulations.

    Risks of Opting for In-Person Services. Please read each statement and answer accordingly.

    * I have been given a choice of in person or tele therapy sessions. I understand that by coming to the office, I am assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. By choosing in-person services, I assume sole risk of exposure to the coronavirus and any other public health risks.
    I agree
     
    I do not agree
     
    * I will only keep my in-person appointment if I am symptom free and have been symptom free for a period of 14 days. Symptoms include recent onset of one or more of the following: body aches, loss of smell or taste, headache, diarrhea, vomiting, coughing, shortness of breath, difficulty breathing, fever, chills, sore throat or any newly discovered health symptom associated with any contagious virus.
    I agree
     
    I do not agree
     
    * I will take my temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if I have other symptoms of the coronavirus I agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I will not charge you the normal cancellation fee.
    I agree
     
    I do not agree
     
    * I will wait in my car or outside until no earlier than 5 minutes before my appointment time.
    I agree
     
    I do not agree
     
    * I will wash my hands or use alcohol-based hand sanitizer when I enter the building.
    I agree
     
    I do not agree
     
    * I will adhere to the safe distancing precautions while in the building. This includes keeping a distance of 6 feet between myself and others and there will be no physical contact (e.g. no shaking hands) with staff of Mana Life Counseling.
    I agree
     
    I do not agree
     
    * I will wear a mask in all areas of the office at all times.
    I agree
     
    I do not agree
     
    * I will take reasonable steps between appointments to minimize your exposure to COVID
    I agree
     
    I do not agree
     
    * If you have a job that exposes you to other people who are infected, you will immediately let me know. This may prohibit you from the ability to participate in in-person sessions.
    I agree
     
    I do not agree
     
    * I understand that if I appear to be physically ill at an appointment, I may be required to leave immediately. If this occurs you will be contacted to reschedule your appointment, possibly temporarily involving tele therapy only sessions.
    I agree
     
    I do not agree
     

    The above precautions may change if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

    Mana Life Counseling's commitment to minimize exposure

    My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Basic precautions and procedures are listed below. Please let me know if you have questions about these efforts.

    Staff of Mana Life Counseling will wear a mask at all times

    Clients will not be allowed to sit on furniture that can not be easily sanitized between sessions. Furniture outside of 331E office, does not belong to Mana Life Counseling and therefore can't be assured of regular sanitization.

    Contact with common surfaces will be limited by not allowing clients to open or close the office door. All common surfaces, within the office, will be sanitized in between each session.

    Hand sanitizer will be available for use within the office.

    Staff will avoid client contact, when feasible, including shaking hands.

    Staff will only keep in-person appointments if they are symptom free and have been symptom free for a period of 14 days. Symptoms include recent onset of one or more of the following: body aches, loss of smell or taste, headache, diarrhea, vomiting, coughing, shortness of breath, difficulty breathing, fever, chills, sore throat or any newly discovered health symptom associated with any contagious virus.

    * By providing my signature I consent I have read, understand and agree to with all parts of this consent.
    By checking this, you are eSigning this form.

    I created one based on a few different ones I reviewed. I don't know how to attach it so I have copied/pasted below for you.

    INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

    * This agreement is between Mana Life Counseling (formerly Heather D Counseling) and
    First and Last Name
    * Date

    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.

    In accordance with local guidelines for the COVID-19 public health crisis, Mana Life Counseling LLC will resume in-person services as of June 1, 2020. If the pandemic or other concerns resurface, you may be required to return to telehealth-only services out of an abundance of caution for everyone’s safety.

    By signing this agreement you acknowledge that you have voluntarily sought in person services and acknowledge that you are increasing your risk of to exposure to the Coronavirus/COVID-19. You acknowledge that you must comply with all set procedures to reduce the spread while attending your appointment.

    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 potential exposure. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.

    If, at any time, you decide 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 determined by the insurance companies and applicable law and is subject to change depending on applicable laws and insurance regulations.

    Risks of Opting for In-Person Services. Please read each statement and answer accordingly.

    * I have been given a choice of in person or tele therapy sessions. I understand that by coming to the office, I am assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. By choosing in-person services, I assume sole risk of exposure to the coronavirus and any other public health risks.
    I agree
     
    I do not agree
     
    * I will only keep my in-person appointment if I am symptom free and have been symptom free for a period of 14 days. Symptoms include recent onset of one or more of the following: body aches, loss of smell or taste, headache, diarrhea, vomiting, coughing, shortness of breath, difficulty breathing, fever, chills, sore throat or any newly discovered health symptom associated with any contagious virus.
    I agree
     
    I do not agree
     
    * I will take my temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if I have other symptoms of the coronavirus I agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I will not charge you the normal cancellation fee.
    I agree
     
    I do not agree
     
    * I will wait in my car or outside until no earlier than 5 minutes before my appointment time.
    I agree
     
    I do not agree
     
    * I will wash my hands or use alcohol-based hand sanitizer when I enter the building.
    I agree
     
    I do not agree
     
    * I will adhere to the safe distancing precautions while in the building. This includes keeping a distance of 6 feet between myself and others and there will be no physical contact (e.g. no shaking hands) with staff of Mana Life Counseling.
    I agree
     
    I do not agree
     
    * I will wear a mask in all areas of the office at all times.
    I agree
     
    I do not agree
     
    * I will take reasonable steps between appointments to minimize your exposure to COVID
    I agree
     
    I do not agree
     
    * If you have a job that exposes you to other people who are infected, you will immediately let me know. This may prohibit you from the ability to participate in in-person sessions.
    I agree
     
    I do not agree
     
    * I understand that if I appear to be physically ill at an appointment, I may be required to leave immediately. If this occurs you will be contacted to reschedule your appointment, possibly temporarily involving tele therapy only sessions.
    I agree
     
    I do not agree
     

    The above precautions may change if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

    Mana Life Counseling's commitment to minimize exposure

    My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Basic precautions and procedures are listed below. Please let me know if you have questions about these efforts.

    Staff of Mana Life Counseling will wear a mask at all times

    Clients will not be allowed to sit on furniture that can not be easily sanitized between sessions. Furniture outside of 331E office, does not belong to Mana Life Counseling and therefore can't be assured of regular sanitization.

    Contact with common surfaces will be limited by not allowing clients to open or close the office door. All common surfaces, within the office, will be sanitized in between each session.

    Hand sanitizer will be available for use within the office.

    Staff will avoid client contact, when feasible, including shaking hands.

    Staff will only keep in-person appointments if they are symptom free and have been symptom free for a period of 14 days. Symptoms include recent onset of one or more of the following: body aches, loss of smell or taste, headache, diarrhea, vomiting, coughing, shortness of breath, difficulty breathing, fever, chills, sore throat or any newly discovered health symptom associated with any contagious virus.

    * By providing my signature I consent I have read, understand and agree to with all parts of this consent.
    By checking this, you are eSigning this form.
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    Gloria Servakh
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    Anne Sinclair

    Thank you, they are very helpful.

    Thank you, they are very helpful.

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    Perette Halpin

    Wow, very comprehensive! Thank you so much!

    Wow, very comprehensive! Thank you so much!

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    Sally Harney

    Thank you both for posting these. It's very helpful.

    Thank you both for posting these. It's very helpful.

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    Sophie Littleton

    Thank you so much for sharing your work on this. 

    Thank you so much for sharing your work on this. 

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    Mary Leopold

    May be a silly question, but is there a way to attach this consent form to Client Portal? If so, how? Thank you!!

    May be a silly question, but is there a way to attach this consent form to Client Portal? If so, how? Thank you!!

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    Heather Dick

    Yes have created this form in my templates and send it to client to sign via the portal

    Yes have created this form in my templates and send it to client to sign via the portal

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    Mary Leopold

    Thank you, Heather! Will do so too!

    Thank you, Heather! Will do so too!