INFORMED CONSENT FOR IN-PERSON SERVICES

DURING COVID-19 PUBLIC HEALTH CRISIS

(Update don 6/12/2021)

The COVID-19/ coronavirus is a serious and highly contagious virus which has required local, state, and federal public health officials to provide guidelines and recommendations 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 considering the COVID-19 public health crisis.  For your safety, the safety of our staff, and community, you must comply with all measures and protocols outlined below to receive in person services (office or school based) from Iowa Family Counseling.  Please note that these protocols are subject to change based on updated information we may receive from various health officials.  Please read this carefully and let us know if you have any questions.

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

All Clients:

1. Are required to complete a self-check for symptoms at least 1 hour prior to coming to 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:

   1. Temperature (100.4° Fahrenheit or higher when taken by mouth)

   2. Sore throat

   3. Uncontrolled cough and/or difficulty breathing)

   4. Diarrhea, vomiting or abdominal pain

   5. New onset of severe headache (especially with a fever)

2. Will be asked the following COVID-19 screening questions about any symptoms you or your child may have prior to your appointment.

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

   2. 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)?

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

3. Understand 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.  Cancelling the session for this reason will not result in a late cancellation charge.

4. With a temperature above 100.4 will not be able to attend their therapy session in-person and will be required to use telehealth for two weeks or until cleared by a doctor.

5. Exhibiting symptoms or believed to have been exposed to COVID must inform their therapist immediately, change to telehealth for 2 weeks and promptly leave the session/office if you entered the office.

6. Must wear a mask when in any common spaces such as the waiting room. The Therapist and client may decide if a mask can be removed during a session.

7. Must wash or disinfect their hands upon entering the building and/or therapy office, after they use the restroom, and after anytime they touch their face.

8. Must attempt to maintain 6 feet of distance from anyone in the building unless they are from the same household.

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

10. Understand that only clients are allowed in the office and therapy session.  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.

11. Are expected to take the appropriate steps between appointments to minimize their exposure to COVID.

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

13. Who test positive for COVID and have attended an in-person therapy session in the past 2 weeks must immediately notify their therapist.  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.

14. That test positive for COVID will have in-person services paused and telehealth will be used for at least two weeks or until the client is cleared by a medical doctor.

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

16. Understand 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 to maintain the safety and well-being of our staff and clients.

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

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 to reduce the risk of spreading the virus within the office and therapy rooms, such as wearing masks, 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 safety protocols.

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.