Willow Ann Rose LPC CHT ~ SpiritWell
South Eugene Wellness Center~Tamarack Building
3575 Donald St. ~ Ste 115
Eugene, Oregon 97405
Phone: 541 461-5424
willowrose@spirit-well.com


COVID-19 HEALTH SCREENING and OFFICE PROTOCOLS

IN ORDER TO BE SEEN “IN OFFICE” YOU MUST AGREE TO THESE GUIDELINES

Your ‘Personal Face Mask/Face Shield’ is required to be worn at all times in the Tamarack Building and in Willow’s Private Office. Willow will be wearing face mask/face shield throughout our session and “in-person” interactions.

Willow’s Office Protocols:

Willow will meet you in the “SpiritWell” waiting area located in the main hallway of the Tamarack Building. If possible, utilize the Waiting Area no more than five minutes prior to start of our scheduled session. Willow will escort you to the office; please allow her to open and close office door. As you enter, please stop to use hand sanitizer just inside office door. In order to maintain physical distancing sit on section of couch with white covering. Please do not bring your own blanket/seat coverings into the office. At this time: pens/paper/water will not be available in office. If desired, please bring your own.


COVID Health Screening Section One:

People who are positive for COVID-19 experience a wide range of symptoms ranging from mild to severe. COVID can infect and be spread to others by people of ALL ages. Symptoms may arise 2 to 14 days after exposure. If you have been infected, you can spread the virus even though you may have “no symptoms.”

The most “common” symptoms may include:
Cough - Chills - Fever - Sore Throat - Muscle pain
Shortness of breath/Difficulty breathing
New Loss of sense of taste or smell
Digestive Issues - Deep Fatigue - New headache

If you have experienced any of the symptoms noted above, either the day of your appointment or within the past 14 days: YOU AGREE TO : IMMEADIATELY CONTACT WILLOW TO CANCEL YOUR IN-OFFICE APPOINTMENT.


COVID Health Screening Section Two:


YOU ALSO AGREE TO CONTACT WILLOW TO CANCEL YOUR CURRENTLY SCHEDULED OR UPCOMING “IN-OFFICE” APPOINTMENT:

If in the past 14 days you can answer “Yes” to Any of the following statements:


I have been in Physical contact with someone known or presumed to have COVID

I have attended a social gathering or event where physical distancing was not maintained
and/or
masks were not worn,
and/or
have traveled to a locale, out of state/country or to an area that is noted to have a high rate of COVID infection

I have been tested for COVID-19 and am currently awaiting results of my test


*****************


In Order to Be Seen “In Office,” Your Signature of Agreement is Required on This Document. This Agreement will be maintained “in force” until Willow Rose LPC CHT chooses to no longer require for “in-office” sessions.

In order to support Healthful Actions for Myself, Family/Community, and also to support the health and well being of Practitioners and other Guests in the Tamarack Building:

I agree to follow the guidelines in this document as noted above and relating to:
“In Office Protocols”
COVID Health Screenings
Section One
Section Two

I will be reminded to review this agreement at scheduling of each session. I will also find a copy of these basic protocols located in the “SpiritWell Waiting Area,” and agree to review these guidelines prior to greeting Willow Rose LPC CHT for our scheduled appointment.

Should I Answer “Yes” to any of the Health Screening Questions, or decided I will not follow the Office Protocols, I will immediately contact Willow to cancel my current or upcoming scheduled “in-office” session(s).


I understand that should I consciously choose to Not Disclose “Positive” COVID exposure or symptoms prior to our scheduled session, Willow Rose LPC CHT retains the right and choice to terminate our therapeutic relationship.


To Cancel our “upcoming session” or session for today, and discuss rescheduling options: call: 541 461-5424 (voicemail only/no text) or willowrose@spirit-well.com)

I am reminded that: Cancellation due to potential COVID exposure will not result in late cancellation fees.


*Client Signature    *Today's Date
By typing my name above, I am electronically signing my form.
* Full Printed Name: * Email:


You will receive an email of your COVID/OFFICE PROTOCOLS Document.
Please be sure your email address is correct above.
You may also print a copy of this page. Please retain for future reference.



Form Revised July 2020