Client/Visitor COVID-19 Declaration Form
Completion of this declaration is voluntary. However, if you choose not to complete this form, we welcome you to connect with your counsellor via LifeStreams.

This form is to be completed on the day of your appointment.
Email address *
Full Name *
Location *
Do you currently have any flu like symptoms (fever, dry cough, difficulty breathing or shortness of breath, muscle aches, fatigue, sore throat, runny nose, headache)? *
Have you experienced any of the following symptoms in the last 14 days or come into contact with anyone who has: fever, dry cough, shortness of breath, or difficulty breathing? *
Did you travel outside of Canada by any means of travel or were you in close contact with anyone who has travelled outside of Canada by any means of travel in the last 14 days? *
Have you knowingly come into contact with anyone with a pre-sumptive or confirmed COVID-19 diagnosis in the last 14 days? *
If you have answered YES to any of the above, please contact your therapist to reschedule.
We require anyone entering the building to wear a mask in common spaces (waiting room, hallway) or when physically distancing is not possible. While at our BPW office you must practice good hygiene measures:
• Sanitize your hands
• Sneeze or cough into your sleeve
• If you use a tissue, discard immediately and sanitize your hands afterward
• Try to avoid touching your face, eyes, nose, or mouth, as much as possible
• Remain at least 6 feet away from others
• Washrooms are only available in case of emergency
• Comply with By Peaceful Waters guidance and directives of local public health

Thank you.
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