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.
WATERLOO - 550 Parkside Drive Unit A08
ALMA - Alma Bible Church - 59 Peel Street East
ARTHUR - Arthur United Church - 101 Tucker Street
ARTHUR - Father’s Heart Healing Ministries - 101 George Street
ELMIRA - Zion Mennonite Fellowship - 47 Arthur Street South
EXETER - Exeter Pentecostcal Tabernacle - 670 Main Street
GUELPH - Parkwood Gardens Community Church - 501 Whitelaw Road
GODERICH - Bethel Pentecostal Assembly - 321 Bayfield Road
HAMILTON - 62 East 24th St
KINCARDINE - The Harbour, a Community Church - 249 Bruce Ave
KITCHENER - Freedom in Christ Pentecostal Assembly - 1643 Bleams Road
LISTOWEL - First Baptist Church - 6161 County Road 86 West
LONDON - 120 Wellington Street – Suite 203
MEAFORD - Knox Presbyterian Church - 197797 Grey Road 7, RR 4
OWEN SOUND - TheXchange Centre - 825 2nd Ave East
PALMERSTON - Palmerston Evangelical Missionary Church - 550 Prospect St
ST. JACOBS - Calvary United Church - 48 Hawkesville Road
STRATFORD (AVON) - Avon Mennonite Church - 90 Greenwood Dr.
STRATFORD (BETHEL) - Bethel Pentecostal Church - 2988 Hwy 7 & 8, R.R.#4
STRATFORD (MEMORIAL) - Memorial Baptist Church - 113 Bruce Street
SUDBURY - Waters Mennonite Church - 540 Greater Sudbury Regional Road 55
WATERLOO - Lincoln Road Chapel - 145 Lincoln Road
WATERLOO - Conestoga Road 210-410
WILMOT - Wilmot Centre Missionary Church - 463 Bleams Road RR 2
WOODSTOCK (INNERKIP) - Innerkip Presbyterian Church - 64 Blandford Street
WOODSTOCK - Church of the Epiphany - 560 Dundas Street
ZURICH - Zurich Mennonite Church - 37818 Zurich-Hensall Road
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
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service