Revised June 2020

    Center for Developing Kids, Inc.

    These COVID-19 forms must be completed by each child’s parent/caregiver and anybody else who will be physically present with the child as part of Center for Developing Kids, Inc.’s provision of services and treatment.

    I, the undersigned parent/caregiver, on behalf of my child, hereby acknowledge that I have been advised of the risks, benefits, and alternatives identified below with respect to COVID-19 and the current pandemic-related changes to my child’s participation in the services, treatment, and care provided by Center for Developing Kids, Inc. and its personnel and providers (hereafter “CDK”). I have had the opportunity to discuss the risks identified below, to ask CDK my questions, and to receive answers to my satisfaction. By signing below, I acknowledge the following on behalf of myself and my child:

    1. Risk of Exposure:
      I understand that, despite CDK’s reasonable efforts to follow public health guidance on reducing the risk of exposure, due to the nature of the testing available at the present time, it is only possible to mitigate, not eliminate, the risk of exposure. I understand that in-person consultations, services, and/or treatments performed at this time, despite my own efforts and those of CDK, may increase the risk of exposure to COVID-19. In other words, even following best practices, it is possible for me and my child, CDK, or healthcare personnel to be unaware that we are contagious even without symptoms, raising the possibility of infection. I am aware that exposure to the novel coronavirus (SARS-CoV-2) and persons with COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to one’s health, and even death.

    2. Current Safety Protocols:
      I understand that infection control and safety protocols may change at any time in response to public health guidelines, and that there is a risk that further research will lead to the conclusion that current practices are insufficient and created risks that might have been avoidable if I had waited for my child’s participation in CDK’s in-person services or treatment.

    3. Option of Delay:
      I have been given the opportunity to postpone my child’s in-person participation in services and/or treatment until the COVID-19 pandemic is under better control and further reduced, but I am electing to have my child participated in CDK’s in-person services and treatment now.

    4. Telehealth:
      I understand CDK may use telehealth before, during and/or after treatment to reduce the number of in-person meetings and the accompanying risks of COVID-19 infection. I understand that as part of this effort my child will be receiving care through interactive audio, video, and other telecommunication technologies with a health professional who is not in the same physical location as me and my child. There is a risk that the quality of my child’s telehealth interaction or consultation will be diminished based on the difficulty of communicating and transmitting information without the benefit of being physically present and receiving non-verbal cues, and that there is greater risk of distraction from participants at remote locations. CDK, my child, and I will see and hear each other electronically, but some information the participants would ordinarily get in-person will be unavailable. There is a risk that, in the event of an emergency, my child and I will be alone and without the benefits of in-person interaction to support us through a moment of difficulty. There is a greater risk of intentional or unintentional violation of the confidentiality of client/patient information when transmitted electronically resulting in risks such as interception, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. There is a risk of technology failure and interruption by a connectivity problem. I will need access to, and familiarity with, the appropriate, working technology for my child and me to participate in the services provided by CDK, with a risk of corruption or technology interruptions. I also agree that my child and I are responsible for timely attendance, and that I remain responsible for adhering to CDK’s “Third-Party Funders,” “Parent Presence,” and “Attendance” policies, and the cancellation fees for missed telehealth appointments.

    5. Right to Decline:
      I have the right to decline services for my child at any time without jeopardizing my child’s access to future care, services, and benefits.

    Center for Developing Kids, Inc.


    1. I, the undersigned parent/caregiver, on behalf of my child, hereby agree by my signature below to the following conditions of my child’s treatment by Center for Developing Kids, Inc. and its personnel and providers (hereafter “CDK”). I understand I must honestly disclose this information to avoid putting myself, my child, and others at risk.

    2. I agree to cooperate and comply with, before, during, and after my child’s participation and treatment, for my child’s protection as well as my own and CDK’s, all COVID-19-related compliance and infection control protocols communicated by CDK. I agree on behalf of my child to cooperate whether or not I personally agree and feel such COVID-19 procedures and/or preventive measures are necessary.

    3. I agree to disclose to CDK any symptoms I am experiencing or have experienced within the past fourteen (14) days that may be related to COVID-19.

    4. I agree to disclose to CDK any symptoms that may be related to COVID-19 that I am aware of as experienced by myself, my child, and/or anyone with whom I have had prolonged, close contact. This includes both family members living with me and any other person or instance through whom or which I may have been exposed to the virus.

    5. I agree to be tested and/or have my child tested upon CDK’s request, at my own expense and regardless of any prior testing, and that the results of that testing must be satisfactory to CDK, before my child may continue to receive in-person services or treatment.

    6. I agree to follow all COVID-19 recommendations by the CDC and state and local public health authorities, and confirm that I, my child, and all persons living with me for the past 14 days have followed all personal hygiene, social distancing and other recommendations, and that adhering to such recommendations is required by CDK.

    If you have questions about this form, please contact the directors, AnjaLi Carrasco Koester and/or Michaelann Gabriele at 626-564-2700.

    Based on the above, I certify that I have read the foregoing COVID-19 Informed Consent and COVID-19 Patient Agreement, had opportunities to ask questions, agree and accept all of the terms above, and voluntarily consent as noted above on behalf of me and my child. I also specifically consent to the uses and disclosures of my child’s health data necessitated by telehealth, including but not limited to videoconferencing, recording and storage of videoconferences, email, text messages, and other digital communications exchanged in the course of care.

    Please sign below.