Informed Consent for In-Person Counselling During the COVID-19 Pandemic

Informed Consent for In-Person Counselling during the COVID-19 Pandemic

All clients who are booked for in-person counselling must read and sign this document. Please read this carefully and let your counsellor know if you have any questions.

Decision to Meet Face-to-Face

The counsellor and client have agreed to meet in person for some or all future sessions. If there is a resurgence of the Covid-19 pandemic or if other health concerns arise, the counsellor may require that sessions occur via eCounselling.

If you have concerns about meeting via eCounselling, please raise these with your counsellor.

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to COVID-19.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions. If you do not adhere to these safeguards, it may result in starting (or returning to) eCounselling sessions. Please initial each to indicate that you understand and agree to these actions:

– I will practice self-assessment for COVID-19 symptoms, and I will only keep my in-person appointment if I am symptom free. ____

– I will wait outside Innova Centre until no earlier than 5 minutes before my appointment time. ____

– I will wear a face covering or non-medical mask when entering Innova Therapy’s locations. ____

– I will use an alcohol-based hand sanitizer when I enter Innova Therapy’s locations. ____

– I will keep a distance of 6 feet from the counsellor and anyone else in the office at all times. ____

– I will make every effort to avoid touching my face with my hands during the appointment. ____

– I will take steps between appointments to minimize my exposure to COVID-19. ____

– If I have a job that exposes me to people who are infected, I will let the counsellor know. ____

– If a resident of my home tests positive for COVID-19, I will inform the counsellor and counselling will resume via eCounselling. ____

The above precautions may be changed if additional local, provincial, or federal orders or guidelines are published. If that happens, we will discuss any necessary changes.

Your Counsellor’s Commitment to Minimize Exposure

Your counsellor is taking steps to reduce the risk of spreading COVID-19 within the office. These include:

• increased cleaning schedule

• access to alcohol-based hand sanitizer

• reducing or eliminating contact with high-touch surfaces. The counsellor is currently unable to accept cash, offer water or tea, lend pens, and will open and close all doors for the client.

• ensuring that chairs in the office are spaced out to a minimum of 6 feet to follow social distancing protocols.

Please let the counsellor know if you have questions about these efforts.

If the Counsellor or Client is Sick

If you arrive for an appointment and your counsellor believes that you have COVID-19 symptoms or believes you have been exposed to COVID-19, your counsellor will have to require you to leave the office immediately.

Your appointment will be rescheduled via eCounselling. If your counsellor tests positive for COVID-19, they will notify you so that you can take appropriate precautions.

If, during a self-assessment prior to the appointment, you notice that you have symptoms of COVID-19, you agree to cancel the appointment or proceed via eCounselling. If you cancel for this reason, no cancellation fee will be charged.

Cancellation Policy

A minimum of 24 hours advance notice is required for the cancellation of appointments for non-medical reasons. The full fee will be charged for late cancellations and missed appointments with less than 24 hours notice for non-emergency reasons.

For ICBC clients, the client is responsible for paying for late cancellations and when they do not show for an appointment.

Your Confidentiality in the Case of Infection

If you have tested positive for COVID-19, your counsellor may be required to notify local health authorities that you have been in the office. If other clients have tested positive for COVID-19, you will be informed and the local health authorities will be informed.

If your counsellor has to report this, they will only provide the minimum information necessary for data collection and will not go into any details about the reason(s) for counselling.

By signing this form, you are agreeing that they may do so without an additional signed release.

If you decide at any time that you would like to have eCounselling sessions, please inform the Counsellor.

By signing below, you are acknowledging that you have read and understood all the above, and you give consent to the above information.

I, ______________________________________________, give consent for in-person counselling from

_______________________________________________ at Innova Therapy Inc. located at 9-1161 The High Street, Coquitlam V3B 7W3.