Informed Consent for In-Person Services During COVID-19 Public Health Crisis

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.

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.


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.

We invite you to view our list of upcoming events and to listen to one of our past events. 

Parent Guide to Assessment

Your Child’s Assessment and Diagnosis
A Guide for Parents

New Patient
Intake Packet

Forms  to be filled out in advance
of your upcoming appointment

Clinicians