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Consent Addendum for In-Person Psychological Services During COVID-19
This page contains important information about in-person services in light of the COVID-19 public health crisis. Please read this carefully and let Dr. Tompkins or her associates know if you have any questions. When you provide consent below, it will be an official agreement between you and Dr. Tompkins.
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, we may need to meet via a telepsychology platform. If you have concerns about telepsychology, we will talk about it first and try to address any issues. You understand that Dr. Tompkins and/or her associates may determine that we need to return to telepsychology for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telepsychology services, I will respect that decision, as long as it is feasible and clinically appropriate (e.g., not for cognitive assessment). Reimbursement for telepsychology services, however, is also determined by the insurance companies and applicable law and it is your responsibility to ensure that your costs are covered.
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 risks). This risk may increase if you travel by public transportation, taxi, 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, Dr. Tompkins and her associates, our families, and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telepsychology arrangement. Your signature on this form indicates that you have read, understood, and agreed to these actions:
  • You will only keep your in-person appointment if you (your child) are symptom free.
  • If you identify any coronavirus-related symptoms, you agree to call Dr. Tompkins or her associates to reschedule your appointment. You will not be charged 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 your 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 rooms. For example, you will not move chairs or sit where we have signs asking you not to sit.
  • Masks are required in the office and will be available for those who do not have one. At times, masks may be removed with appropriate distancing for some cognitive assessment tasks.  
  • You will keep a distance of 6 feet whenever possible and there will be no physical contact (e.g. no shaking hands).
  • You understand that for assessments, it may not be possible to maintain a 6-foot separation for the duration of the assessment and that some materials may need to be passed between yourself (your child) and the examiner. You (your child) and the examiner will engage in frequent hand washing/sanitization and there will be a plexiglass partition between you (your child) and the examiner when a 6-foot separation cannot be maintained.
  • You understand that the use of protective measures (e.g., masks, plexiglass) and physical distancing my impact the standardization and interpretation of tests, to some extent.
  • You (your child) will try not to touch your face or eyes with your hands. If you (they) do, you (they) will immediately wash or sanitize your hands.
  • If you are bringing your child, you will make sure that your child follows all of these protective 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 Dr. Tompkins and her associates know.
  • If your commute or other responsibilities or activities put you in close contact with others (beyond your usual close contacts), you will let Dr. Tompkins and her associates know.
  • If a resident of your home tests positive for the infection, you will immediately let Dr. Tompkins and her associates know and we will then resume (begin) services via telepsychology.
The above precautions may be altered if additional local, provincial, or federal orders or guidelines are released. If that happens, we will talk about any necessary changes.
Our Commitment to Minimize Exposure
Our practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts in the office. Please let us know if you have questions about these efforts.
If You or Our Staff Are Sick
You understand that Dr. Tompkins and her associates are committed to keeping you, ourselves, and all of our families safe from the spread of COVID-19. If you show up for an appointment and Dr. Tompkins or her associates believe that you have a fever or other symptoms, or believe you have been exposed to the virus, we will require you to leave the office immediately. We can follow up with services by telepsychology, as appropriate.
If Dr. Tompkins or her associates test positive for COVID-19, you will be notified promptly so that you can take appropriate precautions. Likewise, if you or a family member test positive for COVID-19, please inform Dr. Tompkins immediately.
Your Confidentiality in the Case of Infection
If you (your child) or one of our staff test positive for COVID-19, we may be required to notify local health authorities that you (your child) have been in the office. If we have to report this, we will only provide the minimum information necessary for data collection and will not go into any details about the reason(s) for your visit(s).  By signing this form, you are agreeing that we may do so without an additional signed release.
Informed Consent
This agreement supplements the general informed consent agreement. Your signature below indicates that you agree to these terms and conditions as they have been outlined above. You are indicating that you have willingly chosen to participate in in-person services and you are not being influenced or coerced to do so by Dr. Tompkins, her associates, or any third party agency (e.g., referral company, insurance company, benefit provider). You acknowledge that you understand and accept the potential risks related to in-person appointments and you release Dr. Tompkins and her associates of any liability related to illness following, or resulting from, any in-person appointment.
Thank you for submitting!
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