Client/Visitor COVID-19 Declaration Form for Individuals 18 Years of Age and Older
This screening tool was issued by the Office of the Chief Medical Officer of Health in Ontario.
Completion of this declaration is voluntary. If you choose not to complete this form, we welcome you to connect with your counsellor via our secure online videoconferencing platform, LifeStreams.

This form is to be completed on the day of your appointment.
Email *
Full Name *
Location *
Do you have a temperature 37.8 degrees Celcius/100 Fahrenheit or higher? *
Do you have a cough or 'barking cough" unrelated to known causes or pre-existing conditions (ex. asthma, COPD)? *
Are you experiencing shortness of breath or difficulty breathing deeply that is unrelated to known causes or conditions (ex. asthma)? *
Do you have a decrease or loss of smell or taste that is unrelated to other known causes or conditions (allergies, neurological disorders)? *
Do you have muscle aches or joint pain that are unusual or long lasting and are unrelated to other known causes or conditions? *
Are you experiencing extreme tiredness that is unusual and unrelated to other known causes or conditions? *
Has a doctor, health care provider, or public health unit told you that you should currently be staying at home? *
In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COIVD-19? *
In the last 14 days have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select "No." *
Have you travelled outside of Canada in the past 14 days and are required by Public Health to quarantine? *
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
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
• Use washrooms only in cases of emergency
• Comply with By Peaceful Waters guidance and directives of local public health

Thank you.
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