Mandatory COVID-19 Screening and Consent

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* 1. What is your and your child's name?

Name

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* 2. Do you have a fever? (temperature is over 38*C)

Yes

No

Temperature recorded as:

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* 3. Do you have any of the following signs or symptoms?

new onset of cough

worsening chronic cough

sore throat

shortness of breath

difficulty breathing

new loss or decrease in sense of taste or smell

runny nose

sneezing (not allergy related)

hoarse voice

nasal congestion

chills

headache

unexplained fatigue or malaise

difficulty swallowing

nausea/vomiting, diarrhea, abdominal pain

None of the above

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* 4. Have you travelled or have had close contact with anyone who has travelled in the past 14 days?

Yes

No

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* 5. Have you had close contact with anyone with respiratory illness or a confirmed or probable/ suspected case of COVID-19?

Yes (if yes, go to question 6)

No (if no, screening is complete)

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* 6. Did you wear the required and / or recommended PPE according to the type of duties you were performing (e.g. shield and mask) when you had close contact wit a suspected or confirmed case of COVID-19?

Yes

No

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* 7. If you have checked "yes" to questions 1, 3 and/ or have signs or symptoms, the session may need to be cancelled, please call us to confirm. If you have answered "yes" to question 5 but "yes" to question 6, you may proceed with your appointment.

The entire team at Engaging Minds Learning Group Inc. have and continue to ensure that measures are taken to thoroughly clean and sanitize the equipment used in the client in home sessions prior to starting and at the end of the session. Additionally, we continue to take extensive measures to thoroughly clean and sanitize the clinic and equipment between each client at the clinic and will not overlap clients who are not in the same therapy bubble without written consent from both families ahead of time. Regardless of the extensive efforts to maintain a safe environment, there remains a risk of COVID-19 transmission which is beyond the control of Engaging Minds Learning Group Inc, it's directors and it's contractors. By checking off this box, you agree to participating in in-person therapy sessions with the understanding there there are associated risks for COVID-19 transmission.

I agree