Consent to Receive Services During the COVID-19 Pandemic


  • This document outlines the requirements to receive clinic and/or in-home services from EBS Early Intervention during the COVID-19 pandemic and outlines the potential risks to continuing services.

    In order to keep us all safe we expect the following from families:
    • Provide EBS Early Intervention staff with regular accurate information about the status of being exposed to someone with COVID-19 symptoms (fever, cough, shortness of breath).
    • Provide EBS Early Intervention staff with 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).
    • Notify EBS Early Intervention staff if anyone in the household has potential allergies to personal protective equipment or disinfectants that may be used before, during, or after sessions.
    • Take a daily temperature of everyone in the household and immediately notify EBS Early Intervention staff if someone has a temperature of 100.4 or higher.

    In addition, we ask that you agree to the following in line with CDC guidelines:

    • 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 disinfectants before and after each session, to include the restroom that the technician will be using.

    The CDC has published the following guidelines: Cleaning and Disinfection for Households
    • 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.
    • Staff will not bring in toys and materials into the home.

    Our staff 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. We will work to reduce the number of staff on each case over the next week. Please be advised that if they become compromised, we will no longer be able to offer services.

    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 (fever, cough, shortness of breath)
    • Any member of the household has a fever of 100.4 or higher

    We are agreeing to continue to provide services to your child within the clinic or in-home 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 offer telehealth services (as allowed by funding sources), 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 video conferencing services to receive services if your insurance payor allows such services.

    By signing this agreement, you are acknowledging that you have read and understand the expectations for your child to continue receiving services from EBS Early Intervention. 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 in the community. 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 Early Intervention and all associated personnel for all aforementioned companies for any and all harm that may come from continuing services during the COVID-19 pandemic.
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