LEAPS AND BOUNDS THERAPY COVID-19 CERTIFICATION OF HEALTH AND PRE-SCREENING (HEALTH QUESTIONNAIRE)

In order to support you and your child during the COVID-19 pandemic, in home Physical Therapy sessions are available per usual but with some updates in policy. In order to promote the ongoing health and well-being of our staff and clients we ask that you certify to the following standards necessary to receive in person physical therapy services with Leaps and Bounds Therapy. Please read each statement in its entirety and answer.
Is your child’s temperature above or equal to 100 degrees F?(Required)
In the past 14 days, have you, your child, or anyone in your household experienced any of the following symptoms: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, persistent pain or pressure in the chest vomiting, diarrhea, sore throat or new loss of taste or smell?(Required)
In the past 14 days, have you, your child, or anyone in your household been in contact with anyone diagnosed with or suspected of having COVID-19?(Required)
Are you at a higher risk for serious illness from COVID-19? (visit https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html)(Required)

IF the answer is YES TO ANY ONE of these questions, please be advised that Leaps and Bounds Therapy reserves the right to cancel/modify an in-person appointment and the option of telehealth will be offered as an alternative.

Please read the following statements and sign below: 1. I certify that I will cancel a scheduled appointment should my child, or someone living in our house become exposed to COVID-19 or test positive with COVID-19. Revised December 5, 2021 2. I understand that anyone attending the session will need to wear a mask (including any children over the age of 2 years old). a. Children follow AAP guidelines for wearing masks and follow CDC guidelines CDC does not recommend masks: i. For children under 2 years of age ii. If wearing the face covering causes the child to increase exposure risk due to them touching their face more frequently. iii. If the child has difficulty breathing with the face covering, is unconscious/ incapacitated, or otherwise unable to remove the cover without assistance iv. If the only face covering available is a possible choking or strangulation hazard.  3. I understand that only 1 family member is to be present in immediate intervention session areas. 4. I understand that we will need to wash our hands with soap and water before and after every appointment for at least 20 seconds. If soap and running water are not available, I will have to have an alcohol -based hand rub that contains at least 60% alcohol 5. I understand that my therapist will bring limited equipment/toys into my home if any and will ask me to supply some materials (toys/equipment/blanket) as needed each session. These materials need to be washed between sessions 6. I understand that we will need to avoid close contact when possible. 7. I understand that therapy outdoors will be preferred when and if possible over therapy in the home. Telehealth is also available as a safe alternative to in home therapy during the COVID-19 outbreak or on an as needed basis in case of sickness or symptoms.

LEAPS AND BOUNDS THERAPY COVID-19 CERTIFICATION OF HEALTH AND PRE-SCREENING (HEALTH QUESTIONNAIRE)

By answering and signing this Leaps and Bounds Therapy Health Questionnaire, I certify that I will ensure the above statements are true prior to each scheduled session and will cancel a session if any of the standards for attending are not met and/or if any of the answers to the statements above are YES.
Child's Name(Required)
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Parent/Guardian's Signature(Required)
By completely this signature field I attest that the above is true and accept the responsibility of signature.
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