This document contains important information about our decision (yours and mine) to initiate, continue or resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.
Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we 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 return to telehealth for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.
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, and other clients 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.
My Commitment to Minimize Exposure
My practice has taken steps to reduce the risk of spreading the coronavirus within the office:
I have taken both doses of the Moderna Vaccine. 2nd dose taken on 02/10/2021
Office seating arranged for appropriate physical distancing.
I will be wearing a mask.
Restroom soap dispensers are maintained and everyone is encouraged to wash their hands prior to entering the office.
Hand sanitizer that contains at least 60% alcohol is available in the therapy & waiting area.
I ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.
I may ask you to text me if it’s ok to come in if I have back to back scheduled appointments.
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
Office toys, pens, art supplies, table & couch are sanitized in between each client as they are used.
Office door knob handles are sanitized in between clients.
If You or I Are Sick
You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an 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 by telehealth 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. By signing this form, you are agreeing that I may do so without an additional signed release.
With full knowledge of the risks involved, you hereby release, waive, discharge Shirla de Magalhaes /Sol Play Child Therapy Inc from any liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by yourself or your child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.
You agree to indemnify, defend, and hold harmless Sol Play Child Therapy Inc and Shirla de Magalhães from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released parties due to injury, loss, or death from or related to COVID-19.
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together. Your signature below shows that you agree to these terms and conditions.
This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.