COVID Waiver

COVID-19 Screening and Consent to Receive In-person Services

Thank you for your patience and understanding during closure of our premises in compliance with the directives from the Premier and Dr. Strang during the COVID-19 pandemic. For all of our safety, please fill out this form prior to each therapy session (until further notice). Be sure that the information given is accurate. Thank you for your understanding and cooperation during this unprecedented time.

* Indicates required field

Client Name *

First

Last

Are you required to self-isolate for any reason due to COVID-19 protocols? *

Yes No

Have you had unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropriate PPE in use)? *

Yes No

The following are a list of COVID-19 symptoms:

Fever (i.e. chills, sweats)
Cough or worsening of a previous cough
Sore throat
Headache
Shortness of breath
Muscle aches
Sneezing
Nasal Congestion/runny nose
Hoarse voice
Diarrhea
Unusual fatigue
Loss of sense of smell or taste
Red, purple or blueish lesions, on the feet, toes or fingers without clear cause

Are you currently experiencing any of these known COVID-19 symptoms: *

Yes No

*If you answered YES to any of the above questions, you will be asked to reschedule your appointment for another day. No cancellation fee will be applied, in this case. Thank you for understanding.*

Please make sure you have carefully read and understood the following before submitting this form.

I hereby acknowledge that I have agreed to meet with my mental health practitioner (the “MHP”) at Acuity Counselling and Therapy Services Inc. (the “Facility”) for the purpose of receiving counselling or psychological sessions (the “Services”).

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that public health authorities still recommend practicing social distancing.

I acknowledge that the Facility has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I acknowledge and accept that there is a risk that I could be exposed to the Coronavirus/COVID-19 while attending at the Facility.

I acknowledge that the Facility and the MHP can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, other Facility clients and their families.

I voluntarily seek services provided by the MHP at Acuity Counselling and Therapy Services Inc. and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I also acknowledge and accept that while receiving services, the MHP may need to be closer than the recommended social distancing guidelines in order to assess and/or treat me. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the MHP. I confirm that any questions that I had regarding the services during the pandemic have been answered by the MHP.

I further acknowledge that there is a possibility that my name, contact information and appointment time may need to be disclosed if required by Health Canada for contact tracing.

I have read and agree to the above
*

Yes No

SUBMIT