Life has changed radically this year. We all want to get back to normal; shaking hands hanging out with friends, family and coworkers but until we can, let me help you through it. We can utilize Telehealth or depending on the day with caution Face to Face sessions.
Feel Like Yourself Again... or Better!
CONSENT FOR TELEHEALTH COUNSELING
Telehealth by Simple Practice is the primary technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. My therapist will email or text me a link to my appointment.
I understand that during the Covid 19 Crisis my therapist is authorized to utilize other mediums to conduct telehealth sessions and to bill my health insurance company. Not all health insurance companies cover telehealth. In the event that internet signal is poor or we are unable to reasonably access Simple Practice Telehealth, my therapist may use alternative portals https://doxy.me/stephaniejw Facetime, Audio phone calls, or Zoom.
Please sign, date and return prior to session. _________________________________
INFORMED CONSENT FOR COVID-19 RISK AND CONTACT TRACING RISK
I understand that I am opting for a face to face counseling session that is not urgent, instead of telehealth. I also understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and that social distancing is recommended. I hereby acknowledge and assume the risk of becoming infected with COVID-19 by choosing a face to face session. I understand the potential risks and complications related to COVID-19. I am aware that my therapist has put in place reasonable preventative measures aimed to reduce the spread of COVID-19. I am aware that anyone at high risk; over the age of 65 or older and / or having pre-existing health conditions is recommended to avoid any non-essential contact. I understand that if a face to face client of my therapist contracts COVID-19 that the Texas DSHS, CDC or authorized government agent may order my therapist to release my name and contact information only, for the purpose of CONTACT TRACING to help slow and contain the spread of the COVID-19 virus in Texas. https://www.dshs.state.tx.us/coronavirus/tracing.aspx https://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm
The Privacy Rule permits a covered entity to use and disclose PHI, with certain limits and protections, for TPO (treatment, payment and healthcare operations) activities [45 CFR § 164.506].
For disclosures not required by law, covered entities may still disclose, without authorization, to a public health authority authorized by law to collect or receive the information for the purpose of preventing or controlling disease, injury, or disability, the minimum necessary information to accomplish the intended public health purpose of the disclosure [45 CFR 164.512 (b)] (Box 1).
I assert that for any face to face session, I am not experiencing currently or within the past seven days:
Cough, Shortness of breath or difficulty breathing, Feeling feverish or having a temperature of 100.0 degrees or more, Loss of taste or smell, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, or Diarrhea.
I have not traveled in the past 14 days to regions heavily effected by COVID-19. I have not been in close contact with anyone diagnosed with COVID-19. I have been practicing safe social distancing and thorough handwashing and / or hand sanitizing.
Please Sign date and return prior to session. __________________________________