Contact Tracing Log
As we move to COVID Alert Level 2, in-person services become possible again!

To do this safely, we are asking clients to complete this form before all in-person sessions to make sure that we have double check each day that no one is sick and to make sure we can easily share the best email/phone number with contract tracers if that becomes necessary.

This information will be kept confidential for up to 4 weeks and will only be used if required by public health rules.

You are also free to use a method that is easier for you if this form is challenging

Thank you,

Shannon Hennig
Inclusive Communication
022 499 6737

Email address *
In the past 14 days, has anyone in your family been sick, in isolation, overseas, tested positive for COVID, or suspected to be in close contact with someone who has? *
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Do you agree to keeping our hands and surfaces clean during the session? We will bring sanitiser. *
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Do you promise to quickly let us know if anyone in your family is exposed to COVID-19? *
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Who is the best person to contact in your family if one of our clinicians is exposed to COVID? *
Your answer
If it becomes necessary for contact tracers to contact you, what is the best way to reach you: *
Your answer
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