Clinical Associates
of the Finger Lakes

In-Person Consent Form


Consent to Initiate or Resume In-Person Services During COVID-19
Child's First Name: Child's Last Name: Date of Birth (MM/DD/YYYY): Service Coordinator (EI): School District (PSE): County: This consent must be completed before initiating or resuming in-person services. I, (Parent/Guardian's Full Name) , consent to have my child’s services delivered in person in my home or at (name community-based location) . Check all service(s) that apply: Special Instruction/Education Speech-Language Pathology Occupational Therapy Physical Therapy Teacher of the Deaf I agree to the conditions below so that my child’s services can be delivered in the safest way possible: Everyone who will be part of the session and is over the age of 2 years will wear a face covering. Everyone who is in the home or location where services are being delivered, but not directly involved in the session, will remain at least 6 feet away from where the session is taking place. Everyone who will be participating in the session will wash their hands with soap and water or use an alcohol-based hand sanitizer immediately before the session begins and immediately after it ends. Providers will bring hand sanitizer to use before and after sessions. I will monitor the health of myself, my child and others in my home for the following symptoms before each visit to make sure that the session does not need to be re-scheduled for at least 14 days later or delivered via teletherapy if I have signed consent for teletherapy: COVID-19 symptoms, such as fever, cough, shortness of breath, chills, muscle pain, sore throat, new loss of taste or smell, etc. Having tested positive for COVID-19 in the past 14 days. Being told by a doctor or a County Department of Public Health team to remain home due to COVID-19. I will inform my provider if anyone in my household has traveled to a country with a CDC level 3 travel health notice ( https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html) or a state with a positive test rate higher than 10 per 100,000 residents, or higher than a 10% test positivity rate, over a seven day rolling average, pursuant to the New York State Department of Health COVID-19 Travel Advisory (https://coronavirus.health.ny.gov/covid-19-travel-advisory). I will notify the therapist/teacher if anyone in my household is sick in advance of the session or when I am asked by the therapist/teacher before the session. If an in-person session must be canceled and replaced with a teletherapy session, the teletherapy session is instead of and not in addition to the in-person session. The therapist will not bring toys or materials into the home that have been used by other children to use during the session other than paper. I understand that telethealth continues to be the recommended method of service delivery during the COVID-19 declared state of emergency. By checking this box, I consent to the services and information contained in this form. This represents my legal electronic signature.

Consent to Initiate or Resume In-Person Services During COVID-19

Child's First Name:
Child's Last Name:
Date of Birth (MM/DD/YYYY):
Service Coordinator (EI):
School District (PSE):
County:

This consent must be completed before initiating or resuming in-person services.

I, (Parent/Guardian's Full Name) , consent to have my child’s services delivered in person in my home or at (name community-based location) .

Check all service(s) that apply:
Special Instruction/Education
Speech-Language Pathology
Occupational Therapy
Physical Therapy
Teacher of the Deaf

I agree to the conditions below so that my child’s services can be delivered in the safest way possible:

Everyone who will be part of the session and is over the age of 2 years will wear a face covering.
Everyone who is in the home or location where services are being delivered, but not directly involved in the session, will remain at least 6 feet away from where the session is taking place.
Everyone who will be participating in the session will wash their hands with soap and water or use an alcohol-based hand sanitizer immediately before the session begins and immediately after it ends.
Providers will bring hand sanitizer to use before and after sessions.
I will monitor the health of myself, my child and others in my home for the following symptoms before each visit to make sure that the session does not need to be re-scheduled for at least 14 days later or delivered via teletherapy if I have signed consent for teletherapy:

COVID-19 symptoms, such as fever, cough, shortness of breath, chills, muscle pain, sore throat, new loss of taste or smell, etc.
Having tested positive for COVID-19 in the past 14 days.
Being told by a doctor or a County Department of Public Health team to remain home due to COVID-19.
I will inform my provider if anyone in my household has traveled to a country with a CDC level 3 travel health notice ( https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html) or a state with a positive test rate higher than 10 per 100,000 residents, or higher than a 10% test positivity rate, over a seven day rolling average, pursuant to the New York State Department of Health COVID-19 Travel Advisory (https://coronavirus.health.ny.gov/covid-19-travel-advisory).

I will notify the therapist/teacher if anyone in my household is sick in advance of the session or when I am asked by the therapist/teacher before the session.
If an in-person session must be canceled and replaced with a teletherapy session, the teletherapy session is instead of and not in addition to the in-person session.
The therapist will not bring toys or materials into the home that have been used by other children to use during the session other than paper.

I understand that telethealth continues to be the recommended method of service delivery during the COVID-19 declared state of emergency.

By checking this box, I consent to the services and information contained in this form. This represents my legal electronic signature.