KID TALK INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS This document contains important information about your decision to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let us know if you have any questions. Once signed, this document is an official agreement between you and Kid Talk Inc. Decision to Meet Face-to-Face We have agreed to meet in person for some or all future therapy sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, we may require that we meet via teletherapy. If you decide at any time that you would feel safer staying with, or returning to, telehealth services, we will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we need to take into consideration. Risks of Opting for In-Person Services You understand that by coming to the office, you and your child are assuming the risk of exposure to the coronavirus (or other public health risk). Your Responsibility to Minimize Your Exposure To obtain services in person, you agree to take certain precautions which will help keep everyone (you, other patients, Kid Talk staff) 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 only keep your child’s in-person appointment if they are symptom free. _____ You will take your child’s temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if they have other symptoms of the coronavirus, you agree to cancel the appointment, proceed using telehealth, or reschedule your child’s appointment. _____ You will wait with your child in your car or outside 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 clinic._____ Adults entering the clinic will provide and wear a mask in all areas of the office. _____ 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 notify Kid Talk staff. _____ If a resident of your home tests positive for the infection, you will immediately notify Kid Talk staff and we will then begin/resume treatment via teletherapy.___ We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will notify you of any necessary changes. Kid Talk’s 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 on our website, in the office and have notified our families via email about our updated clinic procedures. Illness Policy You understand that Kid Talk is committed to keeping you, our staff, and all of our families safe from the spread of this virus. If you show up for an appointment and we believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. If Kid Talk staff test positive for the coronavirus, we will notify you so that you can take appropriate precautions. Confidentiality in the Case of Infection If you have tested positive for the coronavirus, we may be required to notify local health authorities that you have been in the office. If we have to report this, we 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 we may do so without an additional signed release. Your Responsibility to Minimize ExposureYou will only keep your child’s in-person appointment if they are symptom free. You will take your child’s temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if they have other symptoms of the coronavirus, you agree to cancel the appointment, proceed using telehealth, or reschedule your child’s appointment. You will wait with your child in your car or outside 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 clinic. Adults entering the clinic will provide and wear a mask in all areas of the office. 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 notify Kid Talk staff. If a resident of your home tests positive for the infection, you will immediately notify Kid Talk staff and we will then begin/resume treatment via teletherapy. Informed ConsentThis agreement supplements the general informed consent agreement that was agreed to at the initiation of services at Kid Talk. Your signature below shows that you agree to these terms and conditions. Patient/Client Name* Date Month Day Year Signature of Patient OR Guardian (if patient is a minor under the age of 18)*CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
