As a mental health professional, I want you to know that I am diligent in protecting the health and safety of my clients. My practice adheres to the standards for infection control by wearing masks, social distancing, disinfectanting after every session, and utilizing single-use disposable materials. Every effort I have in place is to ensure the safety of my clients.
Symptoms of coronavirus are reported with varying degrees of severity. To ensure your health and safety, and the health and safety of everyone, please reschedule your session if you or a member of your household has a cough, fever, and/or flu-like symptoms. In addition, please reschedule your appointment if you have traveled to any areas within the past 14 days that were high risk for contracting the coronavirus.
Thank you in advance for your understanding and cooperation. My apology that we have to go through such measures for well being. Yet, together, we keep everyone as safe and healthy as possible. If you have questions or concerns, please contact me and I'll be happy to assist you.
Below are the Informed Consent and a COVID-19 Questionnaire that were sent to you with the session information. Please make certain to email the forms back to me no earlier than 2 days before your session.
As with the transmission of any respiratory virus, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that I follow best practices related to recommended universal personal protection and disinfection protocols to limit transmission of all diseases in my office. Despite careful attention to disinfection, there is still a chance that you could be exposed to an illness in the office, just as you might at any other locale.
Although exposure is unlikely, do you accept the risk and consent to treatment? Yes/No
*If No, please let me know on the Contact Form below the Questionnaire.
If you have been exposed to a communicable disease, you may spread the disease. Therefore, prior to each appointment, I'm asking my clients to answer the following questions to reduce the chances of transmission.
Q1: Did you, your child, others accompanying you to today's appointment, or anyone you have recently been in contact with have any of the following symptoms within the last 2 weeks?
* Fever (defined as above 100.4° F degrees)? Yes/No
* Chills? Yes/No
* Cough? Yes/No
* Sore Throat? Yes/No
* Shortness of breath and/or trouble breathing? Yes/No
* Persistent pain, pressure or tightness in the chest? Yes/No
* New loss of taste or smell? Yes/No
If yes to any questions, please provide approximate dates of illness.
Q2: Did you, your child, others accompanying you to today's appointment, or anyone you have recently been in contact with tested positive for COVID-19?
If yes, please provide approximate dates of testing.
Q3: Did you, your child, others accompanying you to today's appointment, or anyone you have recently been in contact with been to a large gathering, public event, or a place where social distancing was not practiced within the last 2 weeks?
*Did you wear a mask? Yes/No
*Did others wear masks? Yes/No
If yes to any questions on the COVID-19 Questionnaire (with the exeption of wearing a PPE), please let me know on the Contact Form below.