Consent to receive home-based and/or clinic-based ST/OT/ABA services during the COVID-19 pandemic:
This document is to outline the requirements to remain eligible for services from EBS Children’s Therapy-GA during the COVID-19 pandemic as well as to outline potential risks to continuing services.
Terms of agreement:
- Provide daily accurate information about the status of being exposed to someone with COVID-19. Provide daily accurate information about the status of all members of the household in regards to showing any signs of COVID-19 as outlined by the CDC (fever, cough, shortness of breath, loss of taste or smell, etc.).
- Take a daily temperature of everyone in the household and immediately notify staff if someone has a temperature of 100.4 or higher
- All members of the household will refrain from public gatherings (anyone that still has to work should remain isolated from staff while rendering services in the home) and will refrain from having visitors to the home
- All members of the household agree to wash hands frequently, to include after sneezing, coughing, blowing nose, touching face, or consuming food or drink.
- If services are being rendered in the home, the space in which the client and clinician will be using must be thoroughly sanitized with CDC approved cleaning products before and after each session, to include the restroom that the clinician will be using.
- Our clinicians will also bring sanitizing spray and/or disinfecting wipes and use it before and after sessions.
- All members of the household agree to use social distancing while interacting with staff at the clinic and while interacting with staff in the home.
- Family members/caregivers visiting the clinic agree to wear a face mask/face covering and observe social distancing at all times.
- In order to assist with social distancing no more than 1 caregiver/family member may accompany the client in the clinic (not applicable for home-based services).
- Clients will make every effort to arrive for appointment on time as scheduling is developed to increase social distancing.
Our staff (which includes therapists and student interns) agrees to follow these same terms. You will be immediately notified should the status of our staff change and potential exposure information will be shared with you while maintaining required confidentiality.
These events render us unable to continue services:
- Not following any of the guidelines listed above
- Any member of the household coming into contact with a confirmed case of COVID-19
- Any member of the household showing signs of COVID-19 as outlined by the CDC
- Any member of the household that has a fever or 100.4 or higher
We are agreeing to continue to provide services to your child within the home-based setting until events render us unable to. This agreement does not guarantee services and does not override any orders that may come from the CDC, Governor, or other governing body. This agreement and the terms of this agreement may change at any time as this situation continues to evolve. In the event that we are no longer able to provide in person services, we will work with you to provide a suggested schedule, list of activities, strategies for teaching, and guidance on managing problem behavior. We will also work with you to set up telehealth video conferencing services to receive parent training services from our clinicians.
By signing this agreement, you are acknowledging that you have read and understand the expectations for your child to continue receiving services from EBS Children’s Therapy-GA. You acknowledge that you are not being forced into this agreement and are signing of your own free will. By signing this agreement, you also acknowledge that there is inherent risk in continuing to receive services either in the home or clinic setting while COVID-19 is still actively spreading. Even with all the precautions we are putting into place, we cannot guarantee that there will not be a transmission of COVID-19 between your household and our staff. By signing this agreement, you acknowledge that you will hold harmless EBS Children’s Therapy-GA, and all associated personnel for all aforementioned companies, for any and all harm that may come from continuing services during the COVID-19 pandemic.