Sample Informed Consent Form

INFORMED CONSENT FOR IN-PERSON SERVICES DURING THE COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision (yours and mine) to begin/resume
in-person services in light of the COVID-19 public health crisis. Our decision is based in part on
recommendations by the Center for Disease Control (CDC), but other factors may be considered.
Some of these include but are not limited to: whether we and our families have been vaccinated, our
health or the health of those we are in close contact with, and risk of exposure outside of this setting.
There may be other concerns that we can talk about.
Please read this carefully and let me know if you have any questions. When you sign this document, it
will be an official agreement between us.
Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the
pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you
have concerns about meeting through telehealth, we will talk about it first and try to address any
issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth
for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I
will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for
telehealth services is also determined by the insurance companies and applicable law, so we’ll discuss
any financial implications if needed.
Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the
coronavirus (or other public health risk). This risk may increase if you travel by public transportation,
cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone
(you, me, and our families, [my other staff] and other patients) safer from exposure, sickness and
possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a
telehealth arrangement. Initial each to indicate that you understand and agree to these actions:
 You will tell me if you’ve been vaccinated. If you haven’t, we’ll talk about the reasons and
whether it’s possible to meet safely in person. ___
 You will only keep your in-person appointment if you are symptom free. ___
 You will only keep your in-person appointment if you have been fever free for a minimum of
10 days prior to our appointment. ___
 You will cancel your appointment if you have been in contact with someone who has tested
positive within the last 14 days. ___
 You will take your temperature before coming to each appointment. If it is elevated (100
Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel
the appointment or proceed using telehealth. If you wish to cancel for this reason, I won’t
charge you our normal cancellation fee. ___
 You will wait in your car or outside [or in a designated safer waiting area] until no earlier than
5 minutes before our appointment time. ___
 You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
___
 You will adhere to the safe distancing precautions we have set up in the waiting room and
testing/therapy room. For example, you won’t move chairs or sit where we have signs asking
you not to sit. ___
 You will wear a mask in all areas of the office (I [and my staff] will too). ___
 You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands)
with me [or staff]. ___
 You will try not to touch your face or eyes with your hands. If you do, you will immediately
wash or sanitize your hands. ___
 If you are bringing your child, you will make sure that your child follows all of these sanitation
and distancing protocols. ___
 You will take steps between appointments to minimize your exposure to COVID. ___
 If you have a job that exposes you to other people who are infected, you will immediately let
me [and my staff] know. ___
 If your commute or other responsibilities or activities put you in close contact with others
(beyond your family), you will let me [and my staff] know. ___
 If a resident of your home tests positive for the infection, you will immediately let me [and my
staff] know and we will then [begin] resume treatment via telehealth. ___
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.
My Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we
have posted our efforts on our website and in the office. Please let me know if you have questions
about these efforts.
If You or I Are Sick

You understand that I am committed to keeping you, me, [my staff] and all of our families safe from
the spread of this virus. If you show up for an appointment and I [or my office staff] believe that you
have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave
the office immediately. We can follow up with services by telehealth as appropriate.
If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate
precautions.
Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities
that you have been in the office. If I have to report this, I will only provide the minimum information
necessary for their data collection and will not go into any details about the reason(s) for our visits.
By signing this form, you are agreeing that I may do so without an additional signed release.
Informed Consent
This agreement supplements the general informed consent/business agreement that we agreed to at
the start of our work together.
Your signature below shows that you agree to these terms and conditions.
_________________________ _________________________
Patient/Client Date
_________________________ _________________________
Psychologist Date
[Below is a sample notice to post in the office / on your website. Customize for your practice.]
Office Safety Precautions in Effect During the Pandemic
My office is taking the following precautions to protect our patients and help slow the spread of the
coronavirus.
 Office seating in the waiting room and in therapy/testing rooms has been arranged for
appropriate physical distancing.
 My staff and I wear masks.
 My staff maintains safe distancing.
 Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
 Hand sanitizer that contains at least 60% alcohol is available in the therapy/testing rooms, the
waiting room and at the reception counter.
 We schedule appointments at specific intervals to minimize the number of people in the
waiting room.
 We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their
appointment times.
 Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized
after each use.
 Physical contact is not permitted.
 Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
 Common areas are thoroughly disinfected at the end of each day.

Sample Informed Consent Form

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Sample Informed Consent Form

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INFORMED CONSENT FOR IN-PERSON SERVICES DURING THE COVID-19 PUBLIC HEALTH CRISIS

Decision to Meet Face-to-Face

Risks of Opting for In-Person Services

Your Responsibility to Minimize Your Exposure

My Commitment to Minimize Exposure

If You or I Are Sick

Your Confidentiality in the Case of Infection

Office Safety Precautions in Effect During the Pandemic

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