Assumption of the Risk, Release of Information, and Waiver of Liability Relating to Coronavirus/COVID-19 for GMH Clients
If you have opted to schedule an in-person appointment at Good Mental Health, LLC, during and/or following the phased re-opening of the State of Florida due to the COVID-19 pandemic, we ask that you complete the following waiver prior to attending your first in-person appointment. Please read and respond to the following statements:
Client Name: *
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. *
Good Mental Health (“GMH”) has put in place preventative measures to reduce the spread of COVID-19; however, GMH cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending in-person sessions at GMH could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I or my child may be exposed to or infected by COVID-19 by attending GMH and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at GMH may result from the actions, omissions, or negligence of myself and others, including, but not limited to, GMH employees, patrons of GMH, or other on-premises therapist, their guest, visitors, or others that may be on the GMH property. *
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or child(ren) (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at an in-person sessions at GMH (“Claims”). *
If you, or our staff at GMH, have tested positive for the coronavirus, GMH may be required to notify local health authorities that you have been in the office. If GMH must report this, GMH will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing below, you are agreeing that GMH may do so without additional authorization. *
On my behalf, and on behalf of my children (if applicable), I hereby release, covenant not to sue, discharge, and hold harmless GMH, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of GMH, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any GMH session. *
By entering your name in the box below, you are effectively providing your signature, indicating that you have read the disclosure statement provided and that the information on this form is true and accurate, to the best of your knowledge. *
For identity verification purposes, please provide the last 4 digits of your social security number: *
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