This document contains important information about our mutual decision to participate in in-person services in light of the COVID-19 public health crisis. Please read this carefully and contact our office if you have any questions.

Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future services. You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risks). This risk may increase if you travel by public transportation, cab, or ridesharing service.

Your clinician will make every effort to maintain physical distancing during your time in the office. However, the administration of certain tests requires that the clinician sits at a table (within six feet) of a child. As noted below, in accord with requirements set forth by the Town of Wellesley we require that all visitors to our office wear masks (including children during testing). Staff also must wear masks.

In addition, during in-office testing, the clinician may decide to administer some measures remotely. This will entail interacting with your child from another room using a monitor and intercom. Decisions about inter-room administration will be made on the basis of a child’s developmental and emotional needs and will be discussed with you ahead of your visit.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone safer from exposure, sickness, and possible death.

We understand that children vary in their developmental preparedness for participation in precautionary measures. We are committed to working with every child and family in the safest manner possible; please speak with your clinician before your appointment with regard to any concerns you have regarding masks, physical distancing, etc.

Please initial each to indicate that you understand and agree to these actions:

✦ You will only keep your in-person appointment if you and your child are symptom-free. Initial:*
✦ You will take your and your child’s temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. THERE IS NO CANCELLATION FEE. Initial:*
✦ You and your child will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. Initial:*
✦ You will wait in your car while your child participates in testing. Should your child require you close at hand during testing, please inform us and alternate arrangements will be made. Initial:*
✦ You and your child will wash your hands or use alcohol-based hand sanitizer when you enter the building. Initial:*
✦ You and your child will adhere to the safe distancing precautions we have set up in the waiting room and testing room. For example, you won’t move chairs or sit where we have signs asking you not to sit. Initial:*
✦ You and your child will wear a mask in all areas of the office. Initial:*
✦ There will be no physical contact (e.g. no shaking hands) with staff. Initial:*
✦ You and your child will take steps between appointments to minimize your exposure to COVID. Initial:*
✦ If you have a job that exposes you to other people who are infected, you will immediately let our staff know. Initial:*
✦ If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let our staff know. Initial:*
✦ If a resident of your home tests positive for the infection, you will immediately let our staff know. Initial:*

We may change the above precautions if additional local, state, or federal orders or guidelines are published.

Our Commitment to Minimize Exposure
Our practice has taken steps to reduce the risk of spreading the coronavirus within the office. Please let us know if you have any questions about these efforts. If anyone on our staff tests positive for the coronavirus, we will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection
If you or your child have tested positive for the coronavirus, we may be required to notify local health authorities that you have been in the office. If we have to report this, we 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. By signing this form, you are agreeing that we may do so without an additional signed release.

Informed Consent
This agreement supplements the general informed consent/business agreements for our practice.

Your signature below shows that you agree to these terms and conditions.