COVID-19 Client Advisory and Acknowledgment
Receiving Speech and/or OT Services with Peer Projects Therapy from the Heart during the COVID-19 Pandemic

You or your child are scheduled to receive in-person services today with one of our Speech and/or Occupational Therapists that will be provided during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other clients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers. Masks are required in the clinic.

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS.

IF YOUR ANSWER TO ANY QUESTION BELOW IS YES, WE MAY ASK YOU TO RESCHEDULE YOUR APPOINTMENT.
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Email *
Child's Name *
IS YOUR CHILD VACCINATED? *
Protocols vary by vaccination status
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD BEEN DIAGNOSED POSITIVE FOR THE COVID-19 VIRUS WITHIN THE PAST 14 DAYS. *
Required
IS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? *
Required
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD BEEN CONSIDERED A CLOSE CONTACT TO ANYONE WHO HAS BEEN DIAGNOSED WITH COVID-19 IN THE PAST 10 DAYS? *
Required
IF YES PROVIDE DATE OF CLOSE CONTACT.
MM
/
DD
/
YYYY
IF YOUR CHILD WAS A CLOSE CONTACT OR TESTS POSITIVE
Close Contact if Vaccinated: Asymptomatic clients allowed to continue with in-person sessions. Test on day 5 if possible

Close Contact if Unvaccinated: In-person sessions on hold for first 5 days after close contact. Telehealth sessions offered. Test on day 5 if possible. Can return to in-person sessions on day 6 if asymptomatic.

Positive Results: In-person sessions on hold for first 5 days. Telehealth sessions offered. If symptoms resolve or if asymptomatic, return to in-person on day 6. Test if possible.

If your child does test positive within a week of an in-person session please inform our office at admin@pptfth.com

Must be 24 hours symptom free without the use of medication.  If symptoms develop get a test and stay home.  

IS YOUR CHILD CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS? *
Check all that apply. Any of the following symptoms office visit is placed on hold and we recommend a Teleheath session until they resolve.
Required
IS YOUR CHILD CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS? *
Please check all that apply. If more than one symptom is selected therapist may ask for more information or recommend a telehealth session.
Required
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD VISITED OR RECEIVED TREATMENT IN A HOSPITAL, LONG-TERM CARE FACILITY, OR OTHER HEALTH CARE FACILITY IN THE PAST 14 DAYS? *
Required
WITHIN THE LAST 10 DAYS, HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD TRAVELED OUTSIDE OF THE COUNTRY FOR GREATER THAN 24 HOURS? (Quarantine for 10 days and continue sessions remotely (if available) unless a negative test is received 3-5 days after returning to the US.)
IF YOU ANSWERED YES TO ANYTHING PLEASE EXPLAIN.
PARENT SIGNATURE: By typing my name below, I confirm that I have answered the questions above truthfully. *
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