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Informed Consent for In-Person Therapy

This document provides a sample informed consent form for psychologists resuming in-person services amid the COVID-19 pandemic. It outlines safety procedures, risks of in-person meetings, and responsibilities of clients to minimize exposure. Psychologists can modify it to fit their practice needs and local public health guidelines. The form should be reviewed and signed by clients in addition to the normal informed consent document.

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Noe Zalameda
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34 views4 pages

Informed Consent for In-Person Therapy

This document provides a sample informed consent form for psychologists resuming in-person services amid the COVID-19 pandemic. It outlines safety procedures, risks of in-person meetings, and responsibilities of clients to minimize exposure. Psychologists can modify it to fit their practice needs and local public health guidelines. The form should be reviewed and signed by clients in addition to the normal informed consent document.

Uploaded by

Noe Zalameda
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

SAMPLE INFORMED CONSENT FOR RESUMING IN-PERSON SERVICES IN THE

AFTERMATH OF THE COVID-19 PANDEMIC (OR OTHER PUBLIC HEALTH


EMERGENCY) - May 5, 2020

From the Tennessee Psychological Association - Director of Professional


Affairs
As Governor Lee has allowed the reopening of portions of Tennessee, more psychologists are
considering reopening their practices to face-to-face service.
 
When- or if- to reopen a practice for face-to-face services is an individual decision that every
psychologist must make.  The decision depends on many factors such as the prevalence of
CVOID-19 in one’s community, one’s personal age and health status, or the age and health
status of members of one's household, and the characteristics of one's practice. Many
psychologists will not be opening their practices for many months. Some will only re-open on a
limited basis. Re-opening may be considered on a case-by-case basis, and does not have to be
all patients or none. Psychologists should NOT feel compelled to open their practices for any
face-to-face services UNTIL they believe that they and their patients will be safe and sufficiently
protected from potential virus transmission.
 
APA has provided the following informed consent document for those psychologists who intend
to re-open their practices for some face-to-face services.  This may be altered by individual
psychologists to fit their needs and preferences. As with any informed consent document, it
should be the basis of a conversation between the psychologist and the patient. The
conversation should emphasize that the precautions are in place to protect both the patient and
the public. Please see the APA information hub for further updates on practice resources in
response to COVID-19. [Link]
-- Best wishes, Denise Davis, Ph.D., TPA Director of Professional Affairs

The following sample informed consent form has been created by APA to help psychologists
transition back to providing face-to-face services in the office in the wake of the pandemic and
the lifting of “stay at home” restrictions. This document contains important safety
considerations to help minimize exposure to the coronavirus. Much of the language was taken
from guidance published by the CDC and WHO and is not intended to be an exhaustive list of
possible actions. Since state and local health authorities may have published additional
guidance where you practice, you are encouraged to modify this template to fit requirements of
your community as well as to the needs of your practice and patients.

This document is designed to be used in addition to your normal informed consent/business


practices form - not as a substitute – therefore it does not contain the many content areas you
should discuss with patients or clients before initiating services (such as your fees, billing and
collection practices, limits to confidentiality, etc…). You should use your normal informed
consent form, and use this template as an addendum when patients are returning to (or
starting) in-person services.
You may also wish to consult with your malpractice insurer for additional content they may
recommend.

[Optional Legal disclaimer]

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

This document contains important information about our decision (yours and mine) to resume
in-person services in light of the public health crisis. Please read this carefully and let me know
if you have any questions. When you sign this document, it will be an agreement between us.

Decision to Meet Face to Face


We’ve agreed that it’s better for us 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 I think it’s clinically appropriate. If you have concerns about going back to
telehealth, we’ll talk about it first and try to address your worries. You understand that I have
the final say if I think it’s best to go to telehealth.

If you decide at any time that you would feel safer staying with, or returning to, telehealth
services I will try to respect that decision, if it is clinically appropriate and feasible under the
telehealth guidance from your state and insurer.

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. Your failure or refusal to adhere to these safeguards may result in
our starting / returning to a telehealth arrangement. Initial each to indicate that you
understand and agree to these actions:
 You will only keep your in-person appointment if you are symptom free. ___
 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 designated safer waiting area] until no earlier
than 5 minutes before our appointment time. ___
 You will wash your hands or use 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 will not shake hands or hug 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. ___
 If you have a job that exposes you to those who are infected, you will 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.___

My Commitment to Minimize Exposure


My practice has taken steps to reduce the risk of spreading the virus 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 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.

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 of the
reason(s) for our visits. By signing this form, you are agreeing that I may do so without an
additional signed release.

If I [or my staff] test positive for the corona virus, I will notify you so that you can take
appropriate precautions.

Informed Consent
This agreement supplements to 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

_________________________ _________________________
Therapist Date

[Below is a sample notice to post in the office / on the website.]

Our/My Safety Precautions in Effect During 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 to
encourage physical distancing.
 Ventilation has been increased.
 We have installed high efficiency air filters.
 My staff and I wear masks.
 My staff maintains safe distancing.
 Restrooms soap dispenser are maintained and everyone is encouraged to wash their
hands.
 Hand sanitizers that contain at least 60% alcohol are available in my office, the waiting
room and check-in counter.
 We schedule appointments at intervals to minimize the number of people in the waiting
room.
 We ask all patients to wait in their cars 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.
 Handshakes and hugs are 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.

Common questions

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Patients agree to only attend if symptom-free, check their temperature before appointments, wait outside until just before the appointment time, wash their hands upon entry, adhere to social distancing, wear masks, and minimize exposure between appointments. Non-compliance may result in reverting to telehealth services .

The pandemic may generate lasting changes in business operations, including sustained telehealth integration, continuous adjustments to in-person service protocols, and ongoing evaluation of local health guidelines. These shifts require flexibility and may alter traditional practice models, impacting client interaction, revenue streams, and operational logistics .

The conversation element of the informed consent is critical; it ensures both parties understand and agree on the precautions' necessity, enhancing protection for the patient and public. This dialogue allows flexibility, addresses concerns, and clarifies expectations, contributing to better mutual understanding and adherence .

Practices can arrange physical spaces to enforce distancing, provide ample sanitation supplies like hand sanitizers, schedule appointments to limit contact, and require mask usage. Clear signage and verbal reminders can reinforce protocols, and understanding the consequences of non-compliance, such as reverting to telehealth, further encourages adherence .

The agreement allows the psychologist to notify local health authorities if a patient tests positive, providing only the minimal necessary information. The psychologist also agrees to notify patients if they or their staff test positive, allowing patients to take necessary precautions. This is done without an additional signed release due to prior agreement terms .

Psychologists should consider the prevalence of COVID-19 in their community, their personal age and health status, the health status of their household members, the characteristics of their practice, and guidance from state and local health authorities. The decision to reopen should be made on a case-by-case basis and not driven by obligation to provide face-to-face services until it is deemed safe .

The agreement stipulates that if there is a resurgence of the pandemic or other health concerns arise, the psychologist may require sessions to return to telehealth if clinically appropriate. It acknowledges the patient's right to express concerns about returning to telehealth, but ultimately the psychologist has the final say on service modality to ensure safety .

If a patient fails to comply with the safety precautions, the agreement allows for the services to be shifted back to telehealth to protect both parties. This shift back to remote sessions could occur without penalty to the typical cancellation policy .

The practice has rearranged seating for physical distancing, increased ventilation, installed high-efficiency air filters, requires masks, ensures staff maintain safe distancing, provides hand sanitizers, schedules appointments to lower waiting room density, and sanitizes commonly touched areas. No handshakes or hugs are permitted, and areas are disinfected daily .

Psychologists must consider state and local health authority guidelines, the unique characteristics of their practice, patient demographics, and additional legal content recommended by malpractice insurers. They also need to ensure the consent aligns with their practice’s business agreement, covering areas like fees, confidentiality, and specific safety measures needed for their setting .

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