COVID-19 contact tracing awareness

With the rise in confirmed COVID-19 cases in Manitoba, contact tracing has become a reality. It is therefore likely that if your therapist becomes infected with the COVID-19 virus that she will be asked by Public Health representatives to provide a list of individuals with whom contact was made over a certain period of time. This would place her in the position of having to disclose the names of the clients she saw in person during that time. This information would only be used for the purpose contact tracing and your therapist would not be sharing any other personal information beyond the individuals’ name, phone number, date/time of contact, and location of contact.

By providing a signature below you are indicating confirmation of the following:

  • that you will conduct a self-screening assessment on the morning of your in-person session and will contact your therapist to cancel your appointment if you have any of the following symptoms:

*fever > 38°C or think you have a fever, or chills
*shortness of breath/ breathing difficulties
*sore throat/ hoarse voice
*vomiting or diarrhea for more than 24 hours
*loss of taste or smell
*runny nose
*muscle aches
*conjunctivitis (pink eye)
*skin rash of unknown cause
*loss of appetite

  • that you have not recently been tested for COVID-19 and are awaiting test results or have otherwise been directed to self-isolate
  • that you have not travelled outside the province of Manitoba in the last 14 days
  • that you have not knowingly been in contact with anyone confirmed, or assumed to have, COVID-19
  • that you are aware that in-person sessions carry an increased risk of contracting viruses such as COVID-19 and that you are aware that your therapist has taken all reasonable precautions to protect both you, and herself, including completing her own self-screening assessment on the morning of your session, frequent handwashing, increased cleaning procedures, physical distancing and the use of masks during the session or as directed by Public Health officials
  • that you are aware that in spite of these precautions, there is no guarantee that you will not become ill and agree to release your therapist from any liability should you contract COVID-19 or any other illness following your session
  • that you have read and have had the opportunity to discuss any concerns related to the COVID-19 precautions or any other issues pertaining to this form prior to signing

Signing below also indicates that you are aware of the potential risk of loss of confidentiality due to the need for your therapist to provide your name to Public Health representatives for the purpose of contact tracing, should this be required.

COVID-19 Screening