Client name _________________________________________________________

Parent/Guardian (if applicable) __________________________________________

give consent to Creekside Counseling and Wellness Center to provide treatment during the events of COVID-19 National Emergency from the period of time June 1, 2020 to December 31, 2020.

I understand that there may be risks being in the proximity of providers, patients and staff, and will hold harmless and indemnify, the practice, owners, therapists, associates, employees, and nurse practitioners, against any claims and actions in the event we become infected with COVID-19 while being treated.

I understand there is much to learn about the newly emerged COVID-19 including how it spreads and is transmitted. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19. I understand that carriers of COVID-19 may not show symptoms but may be highly contagious. I understand that due to the unknowns of this virus and the number of patients that have been in the practice, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment.

I confirm, to the best of my knowledge, that myself or my dependent are well and free of symptoms and have had no contact with an individual diagnosed with COVID-19 within the past 14 days.

I have carefully read this release and understand its contents, and I am signing it on my own free act.


Client signature ______________________________________________________________

Parent/Guardian signature (if applicable) __________________________________________


Date: _______________________