Consent to Receive Speech and/or Occupational Therapy Services During the COVID-19 Pandemic Parent/Guardian First Name:*Parent/Guardian Last Name:*Phone Number:*Email Address:* Patient's Name:* This document is to outline the requirements to remain eligible for services from EBS Children’s Therapy – GA (Formerly Chandler Speech & Language Services) 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). 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 agree to wash hands frequently, to include after sneezing, coughing, blowing nose, touching face, or consuming food or drink. All members of the household agree to use social distancing while interacting with staff at the clinic. 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. Clients will make every effort to arrive for appointment on time as scheduling is developed to increase social distancing. 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. 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 clinic 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, and strategies for teaching. We will also work with you to setup 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. Resources: CDC Guidance for Safety at Home EPA List of Disinfectants for Use Against COVID-19 Date* MM slash DD slash YYYY