COVID-19 Vaccination Verification & Documentation TRCC

Due to COVID-19's capacity to transmit from person-to-person through respiratory droplets, the government of New York City has set recommendations, guidelines, and some prohibitions with which The National Psychological Association for Psychoanalysis (NPAP) adheres to comply.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How will you upload your vaccination and identification? Choose ONE*

Take photoUpload photo from computer
Upload the front photo of vaccination card here
Upload front of photo identification here (NOT front or back of vaccination card).
Upload the front photo of vaccination card here*

Cancelof
Upload front of photo identification here (NOT the front or back of vaccination card).*

Cancelof
Enter TRCC patient ID number. If you are a(an) NPAP member/candidate, enter database user ID. *
For TRCC Patients: Enter your therapist's last name. For NPAP member/candidate: Enter your last name.*
Add KEY CARD number (sequence of numbers printed on the side of the door entry white key card). If you do not have a key card, enter 88888*

NPAP Covid Guidelines, page 2

Please complete and accept the following statement in order to receive clinical services, or practice clinical work at the National Psychological Assoiciation for Psychoanalysis (NPAP).
We’re all in this together!
NPAP is committed to the health and safety of all members, candidates, professional staff and patients who come through our doors at NPAP. These guidelines remain in effect until further notice. (January 2022)

If You Cannot Be Vaccinated
Those who need reasonable accommodations due to a medical condition should contact NPAP administration (admin@NPAP.org).

Photo Id Required
Along with proof of vaccination, all entrants at NPAP 18 years or older must also present a government-issued photo ID, such as a driver's license or passport.

Patients/NPAP community members who do not comply with these protocols will be denied entry or asked to leave the building.

Acknowledgment of Risk
Despite best practices, NPAP’s continued commitment to providing a safe environment and
patient/visitor adherence, certain risk factors related to COVID-19 remain unknown at this time.

By signing this form, you acknowledge you understand the following:

1. The risk of contracting the COVID-19 virus remains higher in any public location, including, but not limited to: outpatient waiting areas, lobbies, elevators, treatment rooms and other common areas.

2. There is a potential for increased medical issues for people who have any underlying medical conditions.
I attest to the above: *

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty: