COVID-19 In-Person Treatment Rules, Screener, & Hold Harmless Agreement
  Please complete and submit this Worksheet in order to attend In-Person Treatment at Dr. Beverly's Facility(ies).
  Please be sure to click on the "SUBMIT" Button at the bottom of this Worksheet after you have completed all items, and before you exit this page so that your Response will be counted.
  Please respond to the following items Truthfully and Thoughtfully.
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Email *
Please type in the first 3 letters of your first name.   *
Please type in the first 3 letters of your last name.   *
What year were you born?   *
Where do you usually attend Sessions? *
Important Information and Basic COVID-19 Related Group Rules (Please initial each section below):
_______ Please plan to start attending DV Groups in-person.  In-Person Treatment is almost always more effective and more meaningful than Treatment over the Internet or over the Telephone.  Always arrive at least 5 minutes early. *
If you answered "No" or "I am not yet sure" to the question above, please state your reason here:
Dr. Beverly's In-Person Treatment Agreement:
* Please note that this Agreement here neither replaces, or discontinues any of the conditions of the DV Offender Treatment Contract.          
*** Also, please note that many of the conditions below MUST be agreed to; otherwise this agreement cannot be executed, and you may not attend In-Person Treatment with Dr. Beverly at this time.  Please also note that they will sure be a time in the near future where In-Person Treatment is likely to be required by Probation, Dr. Beverly, and/or the DVOMB.
_______ It is important to arrive early because due to COVID-related and DVOMB-related policies space at this facility is limited.  --- The Alamosa Group Room Maximum will be 10 Clients at one time.  --- The Monte Vista Group Room Maximum will be 5 Clients at one time.  --- The Trinidad Group Room Maximum will be 8 Clients at one time. *
_______ When arriving for Treatment, Clients should not enter the facility without permission of the Counselor.  If you wait outside, please keep a safe distance from others who are waiting.  Please use text or a wave if there is visual contact, in order to alert Dr. Beverly that you are waiting.  If you smoke cigarettes or consume other products; please do not leave any trash or cigarette buts on or near the property. *
_______ All Clients should bring to all In-Person Sessions: Reading Glasses if they need them; a Black or Dark Blue Pen; and a Willingness to learn how to use the Computer and/or fill out Worksheets.  (If you have a learning challenge that could make this impossible, please let Dr. Beverly know (privately)). *
_______ Dr. Beverly will typically provide hand sanitizer and ask everyone to use it upon entering group. *
_______ Regardless of COVID or any other illness, clients are advised NOT to come to In-Person Treatment if they are experiencing any kind or symptoms or sickness from any illness.   If you are feeling ill, or if you have been around someone who is ill, please DO NOT attend in-person.  Rather, if you feel well enough, please attend via Conference Call for now. *
_______ Expect that upon entering the room, that you will be asked to complete a confidential form related to your most recent Symptoms prior to entering the Room.  It is best if you know about your own Symptoms and your relative Temperature before arrival.  If you have been experiencing Fever, Cough or Breathing Difficulty within the past 12 days, DO NOT ATTEND IN-Person Groups.  You will be accommodated either On-Line or Over the Telephone. *
_______ Please note that in order to attend In-Person Services at this Facility, you will be required to sign this form.  And that upon signing this form, you are acknowledging that should there be a COVID Outbreak that is in any way related to those attending Groups at this Facility, that Dr. Beverly will be required by Law to turn over Contact-Tracing Information to the Health Department (and/or other CDC-Related Entities) which will include, your name, the date(s)/time(s) you have attended here, your age, gender, County of residence, Your Address & Phone Information, Your travel outside of the Country, or contact with people who have travelled outside of the Country since December 2019, and whether you reported experiencing any Fever, Cough or Breathing Difficulties at the time of your visit here. *
_______ If you feel MORE comfortable wearing a mask, this is allowed at all times while in this Facility; as well as during Group or Individual Sessions. *
_______ While at the facility, we will each maintain at least 3-to-6 feet of distance between clients in Individual or Group Sessions.  It is required that all persons in this Facility will maintain at least 3-to-6 feet of distance between clients in Individual or Group Sessions.   *
_______ The Colorado Department of Public Health and Environment also requests that: "Unvaccinated patients and visitors are required to wear masks in health care settings, unless they must be removed for service or would inhibit the patient’s health."  Whether or not you have been Vaccinated, whether or not you choose to disclose this, and whether or not you choose to wear a mask at the Facility are entirely up to you while you are at this facility. *
_______ This meeting room will be sanitized before and after each group meeting. *
_______ As has always been the case, Clients are required to pay for services at the time the services are delivered.  And Clients with IOU's must keep track of their balances and must pay on these IOU's on a weekly basis.  All IOU's must be settled before anyone is allowed to successfully discharge from DV Treatment, be re-admitted to DV Treatment, or have their records transferred to any other provider.  Please come prepared to pay for your services.  There will be a computer with the ability for you to pay for your services by Debit / Credit Cards or Paypal.  This is our preferred method of payment. *
_______ Also, as has always been the case, Clients are required to keep track of their Vouchers.  And Clients are asked to keep in touch with their Probation Officers or Diversion Contacts regarding their Vouchers; as Vouchers are provided by those entities and NOT by Dr. Beverly.  Hence, Clients should always know (not guess) whether or not they have a voucher at the time of the session.  It is important to note that if a Client claims they have a Probation Voucher, but here is no voucher; this will be viewed as unacceptable behavior.  If you have questions about your Vouchers (if they exist at all), please contact your P.O. directly. *
_______ It is understood that if anyone refuses or otherwise fails to comply with the conditions stated in this document; and/or the conditions stated in the DV Offender Treatment Contract; he or she will be asked to leave the In-Person setting immediately and may be barred from attending In-Person sessions from that point forward. *
COVID-19 WAIVER OF LIABILITY AND INDEMNIFICATION
Type you name below as if it were inserted in the blank at the beginning of the Paragraph below.  Also, put today's date beside your name here: *
  I __(your name will go here)__  hereby attest that all of the information I am sharing on this form is truthful and accurate to the best of my knowledge.  I also acknowledge that I understand and agree to the conditions set forth above.  I also confirm here that I fully understand, accept and will follow the above conditions and/or rules above.  Finally, I agree that my affirmation attestation here represents my agreement to hold Dr. Beverly, Dr. William T. Beverly, LCSW, LLC and/or Dr. Beverly's Associates and Employees totally harmless should I contract and illness, virus, infection or other malady as in connection with or as a result of my visit to this facility.
1. I agree that I am personally responsible for my safety and actions while at the in Dr. Beverly’s facility. I agree to comply with all Dr. Beverly’s policies and rules, including but not limited to all Dr. Beverly’s policies, guidelines, signage, and instructions.  Because the Dr. Beverly’s facility is open for use by other individuals, I recognize that I am at higher risk of contracting COVID-19.    With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue Dr. Beverly, his Corporation, officers, agents, servants, independent contractors, affiliates, employees, successors, and assigns (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me related to COVID-19 whether caused by the negligence of the Released Parties, any third-party while at Dr. Beverly’s Facility, or otherwise, while participating in any activity while in, on, or around Dr. Beverly's facility and/or while using any of Dr. Beverly’s facilities, equipment, or materials. *
2. I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of the Dr. Beverly’s facilities, tools, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19. *
3. By signing below I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of Liability and Indemnification requirements contained in this document; I am sufficiently informed about the risks involved in attending Dr. Beverly’s facility and am willing and able to decide whether to sign this document; no oral representations, statements, or inducements apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending to be bound by the same. I agree that this Wavier of Liability shall be governed by and construed in accordance with Colorado law, and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Waiver of Liability as a whole. *
This waiver remains in effect until the State of Colorado lifts all COVD-19 related mandates. *
Screening Questions:  Please circle YES or NO Questions 1 through 7, below:
 1.       I certify that all of my responses to the questions below are accurate and truthful. *
2.  Have you experienced any of the following symptoms in the past 48 hours:  fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *
Please Note Regarding the Question Above:
(If you have had any of the above symptoms in the last 48 hours, DO NOT physically attend Treatment with Dr. Beverly.  Please attend through one of the alternative means.)
 3.  Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19? *
4.  Are you fully vaccinated? *
5. Have you recovered from a documented COVID infection in the last 3 months? *
6. Have you been in close physical contact in the last 14 days with Anyone who is known to have laboratory-confirmed COVID-19? *
7. Have you been in close physical contact in the last 14 days with Anyone who has any symptoms consistent with COVID-19? *
Your Name: *
Current Telephone Number(s): *
Current Mailing Address?  (If Mailing Address and Residence are different, please put your Current Residential Address here):   *
I hereby affirm that I understand and agree to all of the responses that I have give above as well as I agree to the conditions and rules set forth in this document (above). *
Be sure to Click on the "SUBMIT" Button so your work will go to Dr. B.  Thank you for completing this form.  After submitting this form, click on the X at the top right corner of your screen.  Have a nice day?   This Worksheet (c. 2021, Dr. W. T. Beverly).
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