Client Name: _____________________________________________ 

Date of Birth: _____________________________________________  

Today’s Date: ____________________

Care Giver (If patient is under the age of 14 y.o. : _______________________________________

Relationship to Patient: ___________________________

This informed consent form has been created to help mental health professionals transition back to providing face-to-face services in the office in the wake of the pandemic and the lifting of “stay at home” restrictions.  This document contains important safety considerations to help minimize exposure to the coronavirus/ COVID-19.  Much of the language was taken from guidance published by the CDC and WHO and is not intended to be an exhaustive list of possible actions. 


This document contains important information about our decision to resume in-person services in light of the public health crisis. In-person services are only being used for services that therapist and client feel cannot be completed by telhealth services such as EMDR Therapy. Please read this carefully and let us know if you have any questions.  When you sign this document, it will be an agreement between us. In this document, “you” or “yours” represents the patient, patient’s caregiver and or both; “mine” or “me” represents your therapist and/or the company L. L. Mulhollem Counseling and Psychotherapy; and “we” represents the combination of “you/yours” and “mine/me”.

Decision to Meet Face to Face

We’ve 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, however, therapist may require that we meet via telehealth. If you have concerns about going back to telehealth, we’ll talk about it first and try to address the issue. You understand that, if we believe it is necessary, we 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, we will respect that decision, as long as it is clinically appropriate.Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss. 

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus/ COVID-19 (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing 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, and our families, staff, and other patients) safer from exposure, sickness and possible death. Your failure or refusal to adhere to these safeguards may result in our starting / returning to a telehealth arrangement.  Check each to indicate that you understand and agree to these actions:

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

       Your temperature will be taken before each therapy session. You are suggest to also take you temperature prior to each therapy session.

      If your temprature is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.  If you wish to cancel for this reason, I won’t charge you our normal cancellation fee.

       You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. 

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

      You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.

      You will wear a mask in all areas of the office and in the building (I and my staff will too), including upon entering the building. You will not be able to attend therapy if you choose not have a mask or do not have both your nose and mouth covered with the mask, at all times while in the building, unless one of the following reasons (which you mark below) is why you need to remove the mask but only during therapy, respecting the 6 foot rule.

    I am medically unable to wear a mask over a long period of time

   I struggle with the ability to communicate with my therapist while wearing a mask and my therapist and I will honor the 6 foot distance rule during therapy when I am not wearing the mask but will wear the mask prior and after therapy as described above. This situation must be approved by both therapist and client.

  Other reasons: __________________________________________________________

      You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me, staff or anyone in the building. 

      You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. 

      If you are bringing your child, 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. 

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

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

    If a resident of your home tests positive for the infection, you will immediately let me [and/or my staff] know and we will then begin and/or resume treatment via telehealth.

L. L. Mulhollem Counseling and Psychotherapy 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.

My Commitment to Minimize Exposure

L. L. Mulhollem Counseling and Psychotherapy has taken steps to reduce the risk of spreading the virus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts. 

If You or I Are Sick

You understand that I am committed to keeping you, me, [my staff] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office staff] 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.

If I [or my staff] test positive for the coronavirus/COVID-19, I will notify you so that you can take appropriate precautions. 

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus/COVID-19, 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 of 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 to the general informed consent/business agreement that we agreed to at the start of our work together.

Client’s Name: _____________________________________________

Client’s Signature: __________________________________________

Therapist Name: ___________________________________________

Therapist Signature: ________________________________________