Light on Anxiety Consent for In Person Session

Completion of this consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all.
The threat of COVID-19 is ongoing throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, tele-therapy services may not be adequate, and in-person services may be more appropriate.

It is important to consider that, although insurance reimbursement for tele-therapy services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect, and tele-therapy may no longer be reimbursed by your insurance company.

As COVID-19 regulations continue to evolve, LOA may become legally required to disclose that you and I have been in contact, especially if either of us were to test positive or show signs of COVID-19 infection. If I am legally compelled to disclose information, I will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law.

In order for LOA to provide you with in-person services, the following protocols must be followed by patients/clients and providers: Hand sanitizer will be provided at the office entrance and must be used upon entering the office, social distancing requirements must be met and patients & providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: if you do not have a face covering, one will be provided to you.

We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let me know.

If at any point during your treatment with Light on Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 7 days or can provide a negative test result.
Print Name:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
Signature*
By signing above, you acknowledge that you understand that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID - 19 (or any other infectious disease) symptoms and have been symptom free for the appropriate time frame, per CDC guidelines.
Date*
Date Format: MM slash DD slash YYYY

Completion of this consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all.