Informed consent form for return to face-to-face sessions
during the COVID-19 pandemic

 

This document contains information about our decision to resume or begin in person services taking into account the COVID-19 pandemic. Our decision is informed by advice from the Department of Health, public health orders and best practice recommendations. In returning to face-to-face services a number of factors must be considered, including vaccination status, risk of exposure and duty of care to protect individual and public health. There may be other considerations that we can discuss. 

 

Please read this document carefully concerning the risks of opting for in-person services and let me know if you have any questions. When this document is signed, it is considered an official agreement between us. 

 

We have decided to meet in a face-to-face format for the course of our sessions together. If there is an increase in health risk, including a spike in COVID-19 cases or other pandemic related concerns, I may choose to return to sessions via telehealth where appropriate and clinically relevant. You understand that by returning to in-person services in a shared office environment, you are assuming a risk for potential exposure to the virus. 

 

It is important to acknowledge that all parties are responsible for taking relevant precautions to minimize exposure to COVID-19, and keep everyone safe (yourself, myself, other staff, other patients, our families, and our broader community).

To maintain ongoing in person services you:

• will alert me of you vaccination status. If you are not vaccinated or do not wish to disclose your vaccination status we will discuss how best to go ahead with your sessions while maintaining our safety in accordance with our practice’s Covid Safe Plan

• will alert me prior to appointments of any possible symptoms you have experienced, within the 10 days prior to your appointment. 

• will let me know before any appointment if you are unwell or have been in contact with a COVID positive case, and we will reschedule your appointment or make it telehealth if possible

• will sign into my rooms using the relevant, CovidSafe app and QR code or manually sign in with the required details.

 

I 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 practice is operating under a COVIDSafe plan and taking necessary precautions to protect your safety on this premises. If you have any queries about what we are currently doing to ensure we maintain an optimal level of safety, please do not hesitate to discuss these efforts with me. Notably, we are unable to eliminate all risk, therefore if I, or anyone who enters the premises tests positive for COVID-19, I will notify you, so you are informed and able to take the necessary precautions. Additionally, in the case where the clinic has an infection, I may be required to notify local health authorities or government bodies. If this is the case, I will only provide the minimum necessary information (in line with QR code check in data) to the relevant authorities. No further details regarding your interactions with myself, and our work together, will be disclosed.

 

By signing this form, you are providing your consent to the above terms and conditions and agree that information may be released to the relevant authorities where it may be necessary.

 

This agreement is in addition to the general informed consent that we agreed to at the beginning of engagement of services. 

 

Your signature below shows that you agree to these terms and conditions. 

 

_________________________                _________________________

Patient/client                             Date

 

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Psychologist                              Date