COVID-19 Informed Consent & Waiver
for In-Office Services
This document contains important information about your consent to gradually resume in-office services during the COVID-19 pandemic. Please read this carefully. When you sign this document, it will constitute a contract between you and Creative Touch Counseling Center LLC, (hereinafter referred to “The Practice”). The Practice team cares about you and wants you to make an informed decision with your informed consent concerning the return to in office services. Please do not hesitate to call our office for additional information, or any concerns.
Your Responsibility and Commitment to Minimize COVID-19 Exposure
To obtain/resume in office services, you will need to sign this document and agree to take certain precautions to help keep The Practice staff, our families, and other patients safer from exposure to COVID-19, illness and possible death. By signing this document, you agree to follow all of The Practice safety policies and the health guidelines posted by The Centers for Disease Control and Prevention (CDC) to help maintain the safety of everyone who is working and those seeking services from The Practice. Please refer to our “Policies for Resuming In-Office Services” for more details.
If you do not adhere to The Practice “Policies for Resuming In-Office Services,” your appointment will be CANCELED, and you will have to call to reschedule and may be assessed a late cancelation fee. If clients generally do not comply with the policies, this will result in The Practice scheduling only telehealth appointments. The Practice retains the right to deny appointments to anyone not complying with the guidelines and maintains the right to return to telehealth arrangements for clients who we deem to be symptomatic, or otherwise a safety risk, in our sole discretion. The Practice may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will notify you about any necessary changes.
Maintaining Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, The Practice may be required to notify local health authorities that you have been in the office. If you have tested positive and you have been in our office in the recent past, The Practice will also need to inform other clients and staff who you may have crossed paths with you so they know they have had exposure. However, please know that if The Practice has to report this to local health authorities, The Practice will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for your visits. If The Practice informs other clients or staff that an in-office client tested positive, we will not disclose your identity or any identifying information to anyone other than your treating therapist if you have not already done so. By signing this form, you agree that The Practice may do so without an additional signed release.
Please Read Carefully
I understand that The Practice is NOT responsible for the risk associated with returning to in-office services and cannot be sued for any possible exposure to COVID-19. If I contract COVID-19 while seeking in-office services, I will not sue The Practice. As such, and in consideration of the services provided by The Practice, I individually and on behalf of my child(ren), hereby release, covenant not to sue, discharge, and hold harmless The Practice its officers, employees, agents, and representatives of and from any and all claims, including all liabilities, actions, damages, costs or expenses of any kind arising out of or relating to in office services or coronavirus exposure. I understand and agree that this release includes any claims based on the acts, omissions, or negligence of The Practice, its officers, employees, agents, and representatives, whether a coronavirus infection occurs before, during, or after participation in any in-person appointments.
I acknowledge and agree that if I have symptoms or have tested positive for coronavirus, I will inform The Practice, and I agree to seek treatment via telehealth and will NOT return to in office services until a medical doctor or nurse has given me written authority to do so. The Practice retains the right to cancel any appointment for any Client showing symptoms.
I understand and acknowledge that, by coming to the physical office, I am responsible for the risk of exposure to COVID-19 (or other public health risks). I understand that this risk may increase if I have a job that directly/indirectly exposes me to COVID-19 or I travel using public transportation, cab, or ridesharing services, e.g., Uber, Lyft.
I understand that by signing this document, I agree to follow ALL posted safety policies found in the “Policies for Resuming In-Office Services” information sheet, and I will follow guidelines posted by the CDC while seeking in-office services.