Informed Consent for In-Person Services during Covid-19 | Carolynn Brusseau

Carolynn Brusseau, MA, LPC
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085 | 312-600-5367




This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you 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. 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, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.

Risk of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ride-sharing 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, my coworkers and other patents) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting/returning to telehealth arrangement.


INITIAL EACH to indicate that you understand and agree to these actions:

You will come ALONE to your appointment, If you have a POA or guardian, they will come into your session or wait in the car.

You will only keep your in-person appointment if you are symptom free.

You will take your temperature before coming to each appointment, If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or request a telehealth appointment.

You will wait in your car or outside.

You will wash your hands or use alcohol-based hand sanitizer when you enter the building.

You will adhere to the safe distancing precautions.

You will wear a mask in the waiting room and hallways of the office (I and my coworkers will too).

You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands).

If your child is a patient here, you will make sure that your child follows all of these sanitation and distancing protocols.

You will take steps between appointments to minimize your exposure to COVID.

If you have a job that exposes you to other people who are infected, you will immediately let me know.

If you commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know.

If a resident of your home tests positive for the infection, you will immediately let me know and we will then (begin) resume treatment via telehealth.

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.


Our Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the office. You understand that I am committed to keeping you, me, my coworkers and all 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.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to 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 general informed consent/business agreement that we agreed to at the start of our work together.

Your signature below shows that you agree to these terms and conditions.


Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Informed Consent for In-Person Services during Covid-19 | Carolynn Brusseau
lock iconUnique Document ID: 8baae919658695e6eb8c622a5c00e1a00636135d
Timestamp Audit
May 9, 2023 11:55 pm CDTInformed Consent for In-Person Services during Covid-19 | Carolynn Brusseau Uploaded by Jennifer Daniels - IP