Covid-19 Client Waiver


Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Anchorpoint Counseling Ministry is taking extra precautions with the care of every client to include enhanced sanitation/disinfecting procedures in compliance with CDC guidance.

Symptoms of COVID-19 can include (or you may be asymptomatic):

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing

I agree to the following:

  1. I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
  2. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 14 days.
  3. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days.
  4. I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 14 days.
  5. I understand that Anchorpoint Counseling Ministry cannot be held liable for any exposure to the COVID-19 Virus caused by misinformation on this form.
  6. IF I contract symptoms, I agree to notify Anchorpoint that I have created a potential exposure to Anchorpoint so that they can take appropriate precautions.

In an effort to prevent the spread of COVID-19 virus, Anchorpoint is providing Best Practices as it relates to safety and hygiene.

By signing below, I agree to each statement above and release Anchorpoint from any and all liability for unintentional exposure or harm due to COVID-19.

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Signature Certificate
Document name: Covid-19 Client Waiver
lock iconUnique Document ID: 6f70f91d99c92af045dfe61a075f99e0afcebe58
Timestamp Audit
November 24, 2020 4:18 pm EDTCovid-19 Client Waiver Uploaded by Daniel Priore - [email protected] IP 162.144.177.109