In-Person Consent Form During COVID-19
This document contains important information about our mutual decision to conduct 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.
Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions. However, if there is a
resurgence of the pandemic or if other health concerns arise, we may be required on short notice
to continue meeting via telehealth. If you have concerns about using the phone or video for
counselling, we will talk about it first and try to address any issues.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services,
please let me know and we will make arrangements to meet remotely.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the
coronavirus (or other public health risk).
My 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. Please let me know if you have
questions about these efforts.
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 therapists and clients) safer from exposure to the COVID-19
virus. We are asking all clients to do the following:
If you have symptoms of COVID-19, or have been in close proximity of someone who has
confirmed or suspected COVID-19, you will reschedule your appointment or switch to a
telehealth option for the next appointment(s). (Late cancellation fees will be waived).
Wait at your vehicle prior to your appointment until you receive a text/phone call from your
Complete the COVID-19 Screening Questions texted to you prior to your appointment.
Come in to the building once your therapist contacts you to indicate s/he is ready to meet
you at the front door.
Wear a mask at your own discretion. Because of our physical distancing, disinfection and
sanitization protocols, wearing a mask inside of our office is optional. If you chose to wear
a mask, your therapist will offer to wear one as well.
Wash your hands or use the provided alcohol-based hand sanitizer when you enter the
Keep a distance of 2 metres from others in the office.
If you are bringing a child, make sure that your child understands and commits to following
these sanitation and distancing protocols.
Our office may change the above precautions if additional local or provincial guidelines are
published. If that happens, I will be sure to talk with you about any necessary changes.
If Anyone at our Office has Suspected or Confirmed COVID-19
I am firmly committed to keeping you, me, all therapists, clients and all of our families safer from
the spread of this virus. If any client shows up for an appointment with possible COVID-19
symptoms (e.g. fever or other related symptoms), for the sake of caution the client will be asked
to immediately leave the office. We will follow up with services by telehealth as appropriate.
If I, any therapist or client tests positive for the coronavirus, I will notify you so that you can take
appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, to assist in contact tracing I may be required to
notify public health 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 name/signature below shows that you agree to all of the above terms and conditions.
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Client Date
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Client Date
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Therapist Date
Thank you for completing this Consent Form.