Elizabeth Jerison Terry, PhD

Clinical Neuropsychologist • Licensed Psychologist PSY 20657

Bridges to Success

Child and Adult Neuropsychological Assessments
Cognitive Behavioral Therapy

COVID Safety

INFORMED CONSENT FOR IN-PERSON SERVICES
DURING COVID-19 PUBLIC HEALTH CRISIS

Effective Date: August 26, 2020

The following is important information about our decision (yours and mine) to meet in-person during the COVID-19 public health crisis.

Decision to Meet Face-to-Face

We have agreed to meet in person for a final assessment session. For future session (e.g. feedback), or if there is a resurgence of the pandemic or if other health concerns arise, however, I expect that we will 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 meet via telehealth for everyone’s well-being.

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 (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, [my other staff] and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.
  • 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 proceed using telehealth. If you wish to cancel for this reason, I won’t
    charge you any 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 alcohol-based 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 (I will too).
  • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands)
    with me.
  • You will try not to touch your face or eyes with your hands. If you do, you will immediately
    wash or sanitize your hands.
  • You will take steps between appointments to minimize your exposure to COVID.
  • If your 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 delay our appointment appropriately.

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.

My Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the office (see
below). 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, and our families safe from the spread of this
virus. If you show up for your 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 as appropriate.

If I test positive for the coronavirus, 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, 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.

Office Safety Precautions in Effect During the Pandemic

My office is taking the following precautions to protect our patients and help slow the spread of the
coronavirus.

  • Nobody will be seated in the waiting room and office seating in therapy/testing rooms has
    been arranged for appropriate physical distancing.
  • Others who use the space and I wear masks.
  • Others who use the space and I maintain safe distancing.
  • Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
  • Hand sanitizer that contains at least 60% alcohol is available in the therapy/testing rooms.
  • We schedule appointments at specific intervals to prevent people from waiting in the waiting
    room.
  • We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their
    appointment times.
  • Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized
    after each use.
  • Physical contact is not permitted.
  • Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
  • Common areas are thoroughly disinfected at the end of each day.
  • During tests that do not require my presence, I will wait outside the door.