Informed Consent For In-Person Services During Covid-19 Public Health Crisis Form

Welcome to Our Blog!

This blog is written by the clinicians at Jonah Green and Associates, a mental health practice based in Kensington, MD that provides quality services for children, teens, families, and adults. It is intended as a resource for families who are seeking to expand their knowledge about mental health and mental health services, and also as a resource for families who are seeking quality mental health services, especially in the mid-Atlantic region. Please feel free to post questions and comments on any of the entries as well as on any topics or articles from our companion web site www.childandfamilymentalhealth.com.

Decision to Meet Face to Face

You and your therapist agree to meet in person for some or all future sessions. If your therapist believes it is necessary, they may cease office visits and offer telehealth services. If you decide at any time that you do not want to meet in the office, your therapist will offer telehealth services as long as it is clinically appropriate.

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to COVID-19 or other public health risks.

Your Responsibilities to Minimize Risk

You agree to take the following precautions to minimize health risks.
- You agree that you and anyone who comes to the office with you is fully vaccinated if they are eligible.
- You agree to inform your therapist if you or someone who came to the office with you may have been infected with COVID.
This office may change the above precautions if additional orders or guidelines are published by the CDC or other health or Governmental authorities.

Our Commitment to Minimize Risk
- If your therapist or other office staff test positive for COVID, your therapist will notify you.
- If your therapist is not able to ensure confidentiality, they will not inform you if an infected individual who was not a staff person was in this space when you were present. If they are able to ensure confidentiality, they will inform you.
The practice may take additional steps to reduce the risk of spreading the virus within the office, and we will post our efforts in the office. Please let your therapist know if you have questions.

If You Are Sick

If you arrive for an appointment and your therapist or office staff believe that you have a fever or other symptoms, or otherwise believe you have been exposed, they may require you to leave the office.

Confidentiality in the Case of Infection

If you have tested positive for COVID-19, your therapist may be required to notify local health authorities that you have been in the office. If your therapist has to report this, they will only provide the minimum information necessary.

Your signature below shows that you agree to these terms and conditions.
Client's Name*
Name of client or client’s guardian*
Signature of client or client’s guardian*
Date
MM slash DD slash YYYY
Name of client or client’s guardian
Signature of client or client’s guardian
Date
MM slash DD slash YYYY
Email*
Therapist
CAPTCHA

Updated: 5/23/2021

Quality Therapy for You, Your Child, and Your Family

Decision to Meet Face to Face

Risks of Opting for In-Person Services

Your Responsibilities to Minimize Risk

Our Commitment to Minimize Risk

If You Are Sick

Confidentiality in the Case of Infection

Jonah Green and Associates, LLC

RECENT POSTS

SEARCH