DISCLAIMER: Due to parent disclosing current work situation and utilizing appropriate social
distancing measures. We are aware and are making an exception to this informed consent provided the client and technician continue to be symptom free.
This document outlines the requirements to remain eligible for services from EAS during the COVID-19 pandemic and outlines the potential risks to continuing services.
In the interest of staff and client safety, it is our expectation that you:
• Provide EAS Staff with regular accurate information about the status of being exposed to
someone with COVID-19 symptoms (fever, cough, shortness of breath).
• Provide EAS staff with daily accurate information about the status of all members of the
household in regards to showing any signs of COVID-19 as outlined by the CDC (fever,
cough, shortness of breath).
• Take a daily temperature of everyone in the household and immediately notify EAS staff
if someone has a temperature of 100.4 or higher
In addition, we ask that you agree to the following in line with CDC guidelines:
• All members of the household will refrain from public gatherings (anyone that still has to
work should remain isolated from staff while rendering services in the home) and will
refrain from having visitors to the home
• All members of the household agree to wash hands frequently, to include after sneezing,
coughing, blowing nose, touching face, or consuming food or drink.
• If services are being rendered in the home, the space in which the client and clinician will
be using must be thoroughly sanitized with disinfectants before and after each session, to
include the restroom that the technician will be using. The CDC has published the following guidelines:
• All members of the household agree to use social distancing while interacting while
interacting with staff in the home.
• Staff will not bring toys and materials into the home.
Our staff has been made aware of all state and local shelter in place and social distancing
requirements and we will continually keep them up to date on their obligations. We take
these orders seriously and have taken them into consideration when outlining these
requirements. You will be immediately notified should the status of our staff change and
potential exposure information will be shared with you, while maintaining required confidentiality. We will work to reduce the number of staff to only see one to two client
maximum. Please be advised that if they become compromised, we will no longer be able to
These events render us unable to continue services
• Not following any of the guidelines listed above
• Any member of the household coming into contact with a confirmed case of COVID-19
• Any member of the household showing signs of COVID-19 as outlined by the CDC (fever, cough, shortness of breath)
• Any member of the household that has a fever or 100.4 or higher
We are agreeing to continue to provide services to your child within the home setting until events
render us unable to. This agreement does not guarantee services and does not override any orders
that may come from the CDC, Governor, or other governing body. This agreement and the terms
of this agreement may change at any time as this situation continues to evolve. In the event that
we are no longer able to provide in person services, we will work with you to provide a
suggested schedule, list of activities, strategies for teaching, and guidance on managing problem
behavior. We will also work with you to setup video conferencing services to receive parent
training services from our Board Certified Behavior Analyst if your insurance payor allows such
By signing this agreement, you are acknowledging that you have read and understand the
expectations for your child to continue receiving services from EAS. You acknowledge that you
are not being forced into this agreement and are signing of your own free will. By signing this
agreement, you also acknowledge that there is inherent risk in continuing to receive services
either in the home or clinic setting while COVID-19 is still actively spreading. Even with all the
precautions we are putting into place, we cannot guarantee that there will not be a transmission
of COVID-19 between your household and our staff. By signing this agreement, you
acknowledge that you will hold harmless, EAS and all associated personnel for all
aforementioned companies, for any and all harm that may come from continuing services during
the COVID-19 pandemic.