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 mask and nitrile gloves can be provided upon request.

• Tissues, if needed, will be distributed by therapists in individually wrapped containers.

• Hand sanitizer containing at least 70% alcohol will be available in my office.

• All people entering the building will have their temperature taken with a contactless thermometer at the time of entry. If their temperature is 100.0 or above, they will be asked to leave, and 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.
• Trash 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 the appointment.

• All materials that might be shared such as books will 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: o 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 understand 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 informed consent agreement that was agreed upon during the start of

your services here at Families First Therapy LLC.

Signing below attests to your agreement with the following statements:

• 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 further 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, omissions, 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

o I am not experiencing any symptom of illness as outlined above.

o I have not traveled outside of New Mexico within the last 14 days.

o I do not believe I have been exposed to someone with a suspected / confirmed case of the COVID-19.

o I have not been diagnosed with Covid-19.

o 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

• 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

• This liability waiver and release extends to Families First Therapy together with all owners, partners, and

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

I have discussed the consent to in-person services with the client(s). My observations of their behavior and responses

give me reason to believe that this person is fully competent to give informed and willing consent. My signature below

www.steveratcliff.com steve@familiesfirsttherapy.org