I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Abiding Hope Christian Counseling has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Abiding Hope Christian Counseling cannot 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, staff, and other clients and their families.
I voluntarily seek services provided by Abiding Hope Christian Counseling 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 attest that: (Initials will populate at the end of the document)
_______I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
_______I have not traveled internationally within the last 14 days.
_______I have not traveled to a highly impacted area within the United States of America in the last 14 days.
_______I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
_______I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.
_______I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Abiding Hope Christian Counseling from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Abiding Hope Christian Counseling. I understand that this release discharges Abiding Hope Christian Counseling from any liability or claim that I, my heirs, or any personal representatives may have against Abiding Hope Christian Counseling with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Abiding Hope Christian Counseling. This liability waiver and release extends to the center together with all owners, partners, and employees.