- 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.