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.

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 *
DATE *
MM
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DD
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YYYY
TIME *
Time
:
CHILD'S NAME *
PARENT/GUARDIAN NAME *
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD BEEN DIAGNOSED POSITIVE FOR THE COVID-19 VIRUS AT ANY TIME? *
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 EXPOSED TO ANYONE WHO HAS BEEN DIAGNOSED WITH COVID-19 IN THE PAST 10 DAYS? *
Required
DOES YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD HAVE A FEVER (TEMPERATURE OF 100.4 OR HIGHER)? *
Required
DOES YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD HAVE ANY SHORTNESS OF BREATH? *
Required
DOES YOUR CHILD OR ANYONE  IN YOUR HOUSEHOLD HAVE A DRY COUGH? *
Required
DOES YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD HAVE A RUNNY NOSE? *
Required
DOES YOUR CHILD ON ANYONE IN YOUR HOUSEHOLD HAVE A SORE THROAT? *
Required
DOES YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? *
Required
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS? *
Required
HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD LOST YOUR SENSE OF TASTE AND/OR SMELL? *
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 30 DAYS? *
Required
ARE YOU OR ANYONE IN YOUR HOUSEHOLD A HEALTH CARE PROVIDER OR EMERGENCY RESPONDER? *
Required
WITHIN THE LAST 10 DAYS, HAS YOUR CHILD OR ANYONE IN YOUR HOUSEHOLD TRAVELED OUTSIDE OF THE COUNTRY FOR GREATER THAN 24 HOURS? *
Required
PLEASE EXPLAIN IF YES TO ANY QUESTION
IF YOUR CHILD WAS EXPOSED OR TESTS POSITIVE
Exposure: Without a test: 10-day quarantine & 24 hours symptom free.
                  With a test: 7-day quarantine, negative test after 5 days

Positive Results: 10-day quarantine, negative test & 24 hours symptom free

PARENT SIGNATURE: By typing my name below, I confirm that I have answered the questions above truthfully. *
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