I am aware that Atlanta Psychological Services (APS) has put in place preventative measures to reduce the spread of COVID-19. However, I acknowledged that APS cannot guarantee that I, my child, or anyone that accompanies me or my child to the office will not become infected with COVID-19, and that attending an appointment in the office could increase the risk of contracting COVID-19. 

By signing this agreement, I acknowledge the following:

• I am voluntarily choosing to attend an appointment to receive psychological services, for myself and/or for my child, at the office of Atlanta Psychological Services (APS).
• I have not been pressured to make the decision to attend an appointment at this office by anyone else.
• I am aware of the potential health risks because I, and/or my child, could be exposed to other individuals that might have a contagious illness (COVID-19 or any other infectious disease).
• I am willing to take this risk voluntarily, consensually, and of my own free will, for myself and/or my child and anyone who accompanies me to the office.
• I understand that the risk of becoming exposed to or infected by COVID-19 at APS may result from the actions, omissions, or negligence of myself and others, including (but not limited to) any other client and their families, or any employee or staff member of APS.

By making this informed decision to attend an appointment at the office of APS, I am holding APS, and/or any specific individual or staff member who works in the office of APS, harmless from any negative health consequences, or other consequences, for myself and/or my child, that might result from exposure to COVID-19 (or any other infectious disease) at the office of APS.

I voluntarily assume all of the foregoing risks and accept sole responsibility for myself, my child, and/or any person who accompanies me to the office, including but not limited to illness, personal injury, damage, loss, claim, liability, or expense, of any kind, that I or my children or accompanying person may experience or incur in connection with my attendance or my child(ren)’s attendance at in-person appointments at APS. 

On my behalf and/or on behalf of my child(ren) or others accompanying me to the office, I hereby release, covenant not to sue, discharge, and hold harmless APS and its employees or other staff members from any liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.  I understand and agree that this release includes any claims based on the actions, omissions, or negligence of APS, whether a COVID-19 infection occurs before, during, or after participation in any in-person appointments with at APS.