White Lilies

COVID- 19

 We know that there’s widespread concern in our community about the Coronavirus Disease 2019 (COVID-19), and we want you to know that your health is our top priority at Iowa Family Counseling. 

 

Due to this, Iowa Family Counseling is temporarily transitioning to telehealth sessions to ensure that clients continue to have access to care, and to limit exposure. Research shows that this platform can be just as effective as in-person appointments, and we can continue your and/or children’s care without interruption during this time of social distancing. Most insurances cover this service and it was announced March 17th, that those with Wellmark/BCBS insurance, out of pocket costs (including copay and coinsurance) are being temporarily suspended for at least 90 days for telehealth services!

During this time, stress can be amplified by viewing media coverage of this pandemic. Therefore, I encourage you to limit your (and your child/rens) media exposure and utilize resources that are more calming, redirective and less sensationalized. 

For up to date, accurate information regarding COVID-19, please refer to the CDC’s dedicated 2019-ncov website for additional information.  Maintain awareness by checking the official communications from the Centers for Disease Control and World Health Organization.

COVID-19 INFORMED CONSENT

PRECAUTIONS & RESPONSIBILITIES 

Prior to your appointment, please review our current COVID-19 precautions and your responsibilities as a patient by 

following the link below. 

Please sign and return the last page. 

COVID-19 INFORMED CONSENT ACKNOWLEDGEMENT & AGREEMENT

This document acknowledges that you have received and understand Iowa Family Counseling's COVID-19 precautions, as well as your rights, and responsibilities as a patient.

INFORMED CONSENT FOR IN-PERSON SERVICES

 DURING COVID-19 PUBLIC HEALTH CRISIS

 

The COVID-19/coronavirus is a serious and highly contagious virus that has required local, state, and federal public health officials to provide guidelines and recommendations in order to manage the spread of the virus. The staff at Iowa Family Counseling have used these guidelines as the minimum standard for resuming in-person counseling services. 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. For your safety and the safety of our staff and community, you must comply with all measures and protocols in order to receive in-person services (office or school-based) at Iowa Family Counseling Wellness. Please note that these protocols are subject to change based on updated information we may receive from those health officials. Please read this carefully and let us know if you have any questions. Our signatures at the bottom will make this an official agreement and understanding between us. 

 

To obtain services in person, you agree to take certain precautions that will help keep everyone (you, me, our families, and other staff and clients) safer from exposure, sickness and possible death from the coronavirus. If you do not adhere to these safeguards, it may result in our starting/returning to a telehealth arrangement.

  • All clients are required to complete a self-check for symptoms at least 1 hour prior to coming to the appointment, and prior to sending your child client to school for the day if they are participating in school-based service. Symptoms to check should include: 

    • Temperature (100.4º Fahrenheit or higher when taken by mouth)

    • Sore throat

    • Uncontrolled cough and/or difficulty breathing)

    • Diarrhea, vomiting or abdominal pain

    • New onset of severe headache (especially with a fever)

  • All clients understand they will be asked COVID-19 screening questions by their therapist prior to their appointment about any symptoms they have. 

    • Have you traveled out of the country in the past two weeks?

    • Have you experienced any cold or flu-like symptoms in the last 14 days (including but not limited to: fever, cough, sore throat, respiratory illness, difficulty breathing)?

    • Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

  • Iowa Family Counseling reserves the right to cancel a scheduled appointment and/or reschedule using telehealth if a client acknowledges current symptoms or risk factors. Canceling the session, for this reason, will not result in the normal late cancellation charge. 

  • Clients with a temperature above 100.4 will not be able to attend their therapy session in-person and will be asked to engage in telehealth for two weeks or until cleared by a doctor. 

  • It is required that any client exhibiting symptoms or believed to have been exposed, inform their therapist immediately, and promptly leave the session/office; following up with telehealth as appropriate. 

  • All clients, guests, and staff must wear a mask when in any common spaces and in the therapy office.

  • All clients must wash or disinfect their hands upon entering the building and/or therapy office, in addition to after they use the restroom, and anytime they touch their face.

  • All clients and staff must attempt to maintain 6 feet of distance from anyone in the building unless they are from the same household.

  • All clients must wait to enter the office or therapy room until the start time of their session. Please wait outside or in your vehicle until your therapist notifies you that they are ready and/or greets you.

  • Only clients are allowed in the office and therapy sessions. For children under 18, one parent/guardian may accompany the client. Children and family members who are not clients of Iowa Family Counseling are not permitted into the office/session at this time. 

  • All clients are expected to take the appropriate steps between appointments to minimize their exposure to COVID.

  • Clients who identify as a member of the vulnerable/high-risk population must begin/continue teletherapy until further notice. All clients who attend in-person therapy sessions acknowledge and agree that they are not a member of the vulnerable or high-risk population. 

  • Clients who test positive for COVID and have attended an in-person therapy session in the past 2 weeks must notify their therapist immediately. Iowa Family Counseling may be required to notify local public health authorities per local, state and federal guidelines, that you (and/or your child) have been in our office/school. If Iowa Family Counseling must report this, we will only provide the minimum information necessary for their data collection in efforts to maintain your privacy and confidentiality. By signing this form, you are agreeing that Iowa Family Counseling may do so without requiring an additional signed release of information. 

  • If a client tests positive for COVID, in-person services will be paused and telehealth will resume, for the duration of at least two weeks or until the client is cleared by a medical doctor. 

  • In-person visits may not be available for every therapist at Iowa Family Counseling, due to their schedule and personal need. 

  • Iowa Family Counseling reserves the right to require telehealth appointments for any or all clients, versus in-person office/school-based appointments if we feel it is necessary in order to maintain the safety and well-being of our staff and clients.

  • If any therapist or staff at Iowa Family Counseling tests positive for COVID, applicable clients will be promptly notified in order to take the appropriate precautions. 

INFORMED CONSENT FOR IN-PERSON SERVICES

 DURING COVID-19 PUBLIC HEALTH CRISIS

ACKNOWLEDGEMENT & AGREEMENT

Due to the long incubation period of the COVID-19 virus, as well as the reality that an individual may be a carrier of the virus without any symptoms or awareness, face to face contact with any other member of the community increases the risk of transmission of the virus.   

Iowa Family Counseling is taking appropriate steps in efforts to reduce the risk of spreading the virus within the office and therapy rooms, such as enhanced cleaning and disinfecting procedures. These efforts and updated procedures are posted on our website for your information. Please contact Iowa Family Counseling with any questions surrounding these. 

 

Iowa Family Counseling will continue to provide individual, couples, family, and group therapy via a telehealth platform.  We recommend that clients continue to use telehealth for therapy services and that in-person office/school-based sessions be used for clients with whom telehealth is not possible or suggested, such as clients with privacy or safety issues, clients who receive therapy with certain modalities or therapeutic techniques that are not conducive to telehealth (i.e. EMDR, play therapy) and/or clients who need a higher level of care. 

 

By choosing in-person sessions over telehealth, you recognize the increased risk of contracting the virus in the office (and/or school setting) and accept that risk.

 

Client/Guardian Acknowledgement & Agreement

 

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus coming for in-person sessions at the office and/or school.  I understand and accept the additional risk of contracting COVID-19 from contact at this office/school. I also acknowledge that I could contract the COVID-19 virus from a multitude of sources outside this office/school, which would be unrelated to my visit here. I acknowledge it would be very difficult for anyone to prove from whom or where they contracted COVID-19. 

 

I assume the risk for myself (and/or my child) being in this therapy space (office and/or school) and request to proceed with services at Iowa Family Counseling. 



 

______________________________________________

Name Signature Date

409 B Avenue, Kalona, Iowa 52247

P: 641-777-2774

F: 319-333-6098

  • Instagram

©2019 by Iowa Family Counseling LLC