CONSENT TO IN-PERSON SERVICES DURING COVID-19 PANDEMIC

We have all been through a lot lately, and there are many differences in daily life due to this pandemic. We want things to find a new, calm normal. So, if you find these pages a bit daunting, know that you are not alone. We want to provide in-person services if you need them, so we ask to please read this all the way through and please be honest about whether you are able to follow through on these safety precautions. Thank you for sticking with us, we care about you and your loved ones. The following are based on the CDC and State of New Mexico Department of Health guidelines, to ensure the safety of our clients and our staff. We require your help in this matter.

COVID-19 PRECAUTIONS: These precautions include but are not limited to the following:

To obtain services in person, I understand and agree to take the following precautions which will help keep everyone (myself, my therapist, our families, and other clients) safer from exposure and sickness. Failure or refusal to adhere to these safeguards may result in resuming telehealth only services. Please note:

• I am asking that only clients with scheduled appointments come to the office and that people accompanying them remain in their cars or outside the building.
• All clients are asked to wait in their cars or outside until no earlier than 5 minutes before session, doors will remain locked during sessions, the lobby will be closed. I will meet you at the door of the building.
• Everyone in the building will be required to wear a mask at any time they are not able to maintain a minimum  distance of 6 feet. A ma sk and nitrile g loves can be provided upon request .
• T issues , if needed, will be distributed by therapists in individually wrapped containers.
• Hand sanitize r containing at least 7 0% alcohol will be available in my office .
• All people entering the building will have their temperature taken with a contactl ess thermometer at the time of entry. If their temperatu re is 100.0 or above, they will be asked to leave, a nd no in - person services will occur.
• Steve will wipe down and disinfect the entire office after each use.
• Steve will follow handwashing recommendations (at least 20 sec with warm soapy water) before all sessions .
• T rash is easily accessed and disposed of on a frequent basis.
• Steve and client are required to self - quarantine if either of us have travelled out of New Mexico within 14 days of t he appointment.
• A ll materials that might be shared such as books w ill not be available for check - out .
• All drinks and snacks previously available will be unavailable until the precautions are lifted by the CDC.
• Steve will implement other precautions as needed or indicated by the CDC.
• Steve will keep you advised as to any further impacts on services.
• Steve and clients: If a resident of your home tests positive for Covid-19, or you are notified that you have come into contact with someone who is infected, you are agreeing to immediately let me know.
• Steve and clients must remain home if experiencing (or are exposed to anyone else experiencing) any symptoms which may indicate Covid-19 infection. The following are some of the symptoms of COVID-19:
  • Fever / chills, Cough, Shortness of breath, difficulty breathing, Fatigue, body aches, Headache, Loss of taste / smell, Sore throat, Congestion / runny nose, Nausea / vomiting, & Diarrhea.

In the unlikely event that I or anyone I have been in contact with tests positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If this occurs, 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 we may do so without an additional signed release.

• I under stand that by coming to the office, I am assuming the risk of exposure to the coronavirus (or other public  health risk This risk may increase if I travel by public transportation, cab, or ridesharing service.
• This agreement supplements the general inform ed consent agreement that was agreed upon during the start of  your services here at Families First Therapy LLC .

• I acknowledge the contagious nature of the COVID - 19 and that the CDC and many other public health authorities  still recommend practicing social distancing.
• I further acknowledge that Families First Therapy LLC has put in place preventative measures to reduce the
• I furthe r acknowledge that Families First Therapy LLC cannot guarantee that I will not become infected with the  Covid - 19. I understand that the risk of becoming exposed to and/or infected by the COVID - 19 may result from  the actions, omissio ns, or negligence of myself and others .
• I voluntarily seek services provided by Families First Therapy LLC and acknowledge that I am increasing my risk to  exposure to the COVID - 19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
• I attest that:
  • I am not experiencing any symptom of illness as outlined above .
  • I have not traveled outside of New M exico within the last 14 days.
  • I do not believe I have been exposed to someone with a suspected / confirmed case of the COVID - 19.
  • I have not been diagnosed with Covid - 19 .
  • I am following all CDC recommended guidelines as much as possible , limiting my exposure to COVID - 19.
• I hereby release and agree to hold Families First Therapy LLC harmless from, and waive on behalf of myself, my  heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act  of the company , or that may otherwise arise in any way in connection with any services received from Families First Therapy LLC.
• I understand that this release discharges Families First Therapy LLC from any liability or claim that I, my heirs , or  any personal representatives may have against the company with respect to any bodily injury, illness, death,  medical treatment, or property damage that may arise from, or in connection to, any services received from Families First Therapy LLC.
• This liab ility waiver and release extends to Families First Therapy together with all owners, partners, and employees.

My signature below attests to the fact that I have read this form, understand it, and agree to these conditions.