Consent for In-Person Session During COVID-19

Dear Client,

You have been contacted prior to the scheduled appointment with the option to cancel and reschedule the appointmentand/or proceed with a video or phone appointment with no penalty inlight of the COVD-19 pandemic.

We have mutually agreed to have an in-person counselling/therapy session. Please review and provide your consent to the following:

Before you enter the office:

• You are assuming the risk of exposure to the Coronavirus for an in-person session
• You will let us know if you have been exposed to anyone with the Coronavirus
• You will let us know if you if you travelled outside of the Province or Canada in the past 14-days
• You will be symptom-free and have undergone the current online assessment tool: https://covid-19.ontario.ca/self-assessment/
• You will sign an additional COVID-19 screening at the time of the appointment

Once you enter the office:

• You will not have anyone not scheduled for the appointment accompany you to the office unless necessary
• You will wear a mask before entering the office
• You will immediately wash your hands with soap or use a hand sanitizer upon entry to the office
• You will also wash you your hands with soap or use a hand sanitizer upon leaving the office
• You will complete and sign the COVID-19 screening questionnaire
• We will keep a physical distance of at least 6 feet or 2 meters
• There will be no physical contact or handshake at all times
• You will use the washroom only to wash hands unless absolutely necessary

We will strictly adhere to all the public health guidelines and protocols around sanitizing of the office at all times. We have to keep a daily log of all persons entering the office (staff and clients), in order to allow for contact tracing should a case of COVID-19 be associated with our office. The log will be shared with public health if needed/requested. We may also be required to notify public health if you present with probable symptoms of COVID-19. We will only provide the minimum information necessary for their data collection. By signing this document, you are agreeing that I may do so without any additional signed release.

Please Select Yes or No to the following questions:

Do you have any of the following symptoms/signs?

If you answer Yes to any of the above questions, you will be asked to leave the office and present the nearest assessment center to your place of residence.