OTTAWA ART THERAPY HEALTH ASSESSMENT

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The health & safety of our team members, clients and their families is our top priority! In an effort to protect you and them from COVID-19, everyone must fill out this questionnaire prior to the attending the centre.

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Name of centre attendee: *

Name of person filling out form:

E-mail address: *

1. Do you have any of the following symptoms (select below all that apply): *

Fever

Worsening Cough/Difficulty Breathing

Chest Pain

Chills

Feeling sluggish/confused

2. Have you traveled outside of Canada in the last 14 days? *

3. Have you had contact with anyone with acute respiratory infection symptoms that has traveled outside of Canada in the last 14 days?

4. Have you been committed to practicing physical distancing and regulations put in place to limit contact & spread of COVID-19?

5.Have you tested positive for Covid-19 in the last 14 days?

6. Do you have any of the following symptoms: nausea, vomiting, diarrhea, stomach pain, unusual fatigue, runny nose, sore throat, rash, swollen eye(s), lice

7. Based on the ledger below, have you passed the health assessment?

I hereby confirm that the information entered in this form is true & understand the repercussions of entering false information & therefore not abiding by the health & safety regulations in place.

Note: Fields marked with * are required

HEALTH ASSESSMENT LEDGER:

# 1: YES= failed assessment, get tested for COVID-19, return to centre once negative result is obtained.

#2: YES= failed assessment. Please quarantine for 14 days & return to centre once Health Assessment is passed

#3: YES= failed assessment. Please quarantine for 14 days & return to centre once Health Assessment is passed

#4: NO= failed assessment. Please return to centre once Health Assessment is passed

#5: YES= failed assessment, return to centre once negative result is obtained.

#6: YES= failed assessment. Return to centre 24 hours after symptoms subside and not controlled with medication.

If you have answered NO to questions 1-3, 5 &6, and YES to question 4, you have passed the Health Assessment. Please come in for your scheduled appointment.

If you have failed the health assessment, and are scheduled to come in, please contact Ottawa Art Therapy Inc, immediately.

H.A. QUESTIONNAIRE

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INSURANCE & FUNDING

Info on insurance providers and funding accepted can be found under the Princing section or by contacting us.

SATURDAY GROUP:

Registration open Feb-April

MUSIC:

Interested in music as skill development and self-expression? Please inquire for more details!

AN INTERVENTION FOR ALL:

Ottawa Art Therapy offers sessions for all individuals AND groups! If you, your child, your family, or your organization is interested in Art Therapy, please contact us.

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