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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.

Masks must be worn in the waiting room.
I will provide hand sanitizer in my office to use upon entry and as needed.
Any toys that are communal (such as games or fidgets) will be disinfected between sessions to the best of my ability.
To obtain services in person, you agree to take reasonable safety precautions to reduce exposure from any contagious illness. If you do not adhere to these safeguards, it may result in immediate changes in our meeting arrangement.

By signing this form, you agree to adhere to each of the following:

I agree to only come to an appointment when I and my child, are symptom free and have been symptom free for a period of 14 days (as recommended by the CDC). (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 to take my and my child’s temperature before coming to each appointment. If it is elevated (99 Fahrenheit or more), or if I or my child present other symptoms, I agree to cancel the appointment before the scheduled time. If I cannot take the temperature before our appointment, I agree to a temperature check with an instant-read thermometer at the office upon arrival.
I agree to follow the rules about arriving to the appointment noted above.
If I or my child have been exposed to, shared a workspace or living arrangement with a person infected by COVID-19, I will immediately disclose the information in advance of our appointment time by phone or email and we will work together to set up a new meeting time or possible alternative means of communication.
I understand that if I or my child appears to be physically ill at an appointment, we may be required to leave immediately and understand I will be contacted to reschedule our appointment, possibly temporarily involving another form of communication.
The above precautions will be adjusted, if additional local, state or federal orders or guidelines are published. If that happens, the content may be subject to change, and we will review the changes.

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Signed by Jordana Wolfson
Signed On: February 25, 2022

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August 3, 2020 1:03 pm EDT

12. Consent for In-Person Services During Covid-19 Public Health Crisis Uploaded by Jordana Wolfson - jordana@coparentingsolutionsllc.com IP 68.60.107.55