In light of the COVID-19 pandemic, we are requiring all clients to complete and submit this form prior to each office visit. The health and safety of our clients, our counselors and our staff is our first priority.
  • Hidden
    MM slash DD slash YYYY
  • I attest that:

    • I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
    • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. 
    • I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
    • I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
    • I have not traveled internationally within the last 14 days.
    • I have not traveled to a highly impacted area within the United States of America in the last 14 days. If so, please tell us where you traveled to and your dates of travel:
  • I acknowledge the following:

    • The contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. 
    • Rogue River Counseling has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
    • Rogue River Counseling cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, counseling staff, and other clients and their families.
    • I voluntarily seek services provided by Rogue River Counseling and understand that I am increasing my risk to exposure to the Coronavirus/COVID-19. I will comply with all set procedures to reduce the spread while attending my appointment.
  • I hereby release and agree to hold Rogue River Counseling harmless from, and waive on behalf of myself any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the counseling practice, or that may otherwise arise in any way in connection with any services received from Rogue River Counseling. I understand that this release discharges Rogue River Counseling from any liability or claim that I, my heirs, or any personal representatives may have against the practice with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Rogue River Counseling. This liability waiver and release extends to the counseling practice together with all therapists and other employees.

  • Type your name below to use as your signature for this document.
  • This field is for validation purposes and should be left unchanged.