Rebecca M. Fishaut, MSW, LICSW, PLLC
1417 NW 54th St, #334, Seattle, WA 98107
becca@rebeccamfishaut.com
(425) 954-7473
INFORMED CONSENT FOR IN-PERSON SERVICES
This document contains important information about our decision (yours and mine) to begin/resume in-person services. Our decision is based, in part, on recommendations by the Centers for Disease Control (CDC) the Washington State Department of Health, but other factors may be considered. Some of these include but are not limited to whether we and our families have been vaccinated against COVID, 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 we 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. However, if there is a resurgence of the pandemic or if other health concerns arise, 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, if 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.
We will discuss whether or not we will wear masks during each session, once we are in my office and out of common building space. This decision will be based on risk factors, community rates of infection, vaccination status, personal preferences, and government guidance and legislation. You will never be required to remove a mask and can always ask me to wear one.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming a risk of exposure to COVID. 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, 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 telehealth arrangement.
· You attest that you have been fully vaccinated and are at least two weeks past your final dose.
· 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 or have tested negative for COVID if you have had a fever.
· You will cancel your in-person appointment if you have been in contact with someone who has tested positive within the last 14 days and haven’t had a negative COVID test, adhering to appropriate testing window.
· You will take your temperature before coming to each appointment. If it is elevated (100 degrees Fahrenheit or more), or if you have other symptoms of COVID, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I won’t charge you my normal cancellation fee.
· You will wait in your car or outside the building until no earlier than 5 minutes before our appointment time.
· You will wash your hands upon entering my office.
· You will adhere to precautions requested and posted by the building management (eg. masking where required).
· You will take steps between appointments to minimize your exposure to COVID.
· If you test positive for COVID or learn you may have been exposed to someone who was infected, you will let me know immediately so that I am able to notify others who have been in my office and take precautions myself.
I may change the above precautions in accordance with local, state, or federal orders or guidelines. If that happens, we will talk about any necessary changes.
My Commitment to Minimize Exposure
I have taken steps to reduce the risk of spreading COVID within the office. I have a sink for easy handwashing and will provide soap and paper towels. Hand sanitizer will also be available. I have two windows that open for cross-ventilation, and I have a fan/air conditioner and an air filter for further air movement in the space. The space is large enough that we can comfortably be 6 feet or more away from each other. I will be frequently cleaning surfaces that are frequently touched (doorknob, faucet). I will not be providing water or tea to my clients for the foreseeable future though you may bring your own beverage. My clients and I are the only people who occupy my office. The management company that maintains the building has also COVID-prevention procedures in place.
If You or I Are Sick
You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I 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 test positive for COVID, I will notify you so that you can take appropriate precautions. If I am concerned that I may have been exposed to someone with COVID or have symptoms that are of concern, I will cancel our appointment or shift it to telehealth until I am well and/or have tested negative for COVID, adhering to appropriate testing window.
Your Confidentiality in the Case of Infection
If you have tested positive for COVID, I may be required to notify local health authorities that you have been in the office. If I must 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 disclosures and agreements that we signed at the start of our work together.