Art Therapy COVID-19 Protocol Consent Form

Client Information

Full Name Date of Birth Email Address

COVID-19 Symptoms Screening

I do not currently have any symptoms of COVID-19 (fever, cough, shortness of breath, etc.). I have not been diagnosed with COVID-19 in the past 14 days. I have not been in close contact with anyone confirmed with COVID-19 in the past 14 days.

Consent to Art Therapy Services

I understand that the COVID-19 virus has a long incubation period. I acknowledge that in-person art therapy sessions may increase my risk of contracting COVID-19.

I consent to receive in-person art therapy services at my own risk and agree to follow the health and safety protocols.

Signature

Signature Date