Coronavirus (Covid-19) Exposure Form Use this form if you have been exposed, or suspect you have been exposed to the Coronavirus (Covid-19). Also use this form to update any information from previous forms submitted. Date MM slash DD slash YYYY Submitted By InformationName: First Last Suffix Phone (Mobile):Phone (Alternate)Email Relationship to Still Waters Professional Counseling Services, Inc. (Still Waters): Select All Employee - Provider Employee - Staff/Management Contractor - Provider Building Tenant Client/Client Family Member or Associate Other (Describe below) Select all that apply.If "Other" selected please describe your relationship to Still Waters:Coronavirus (Covid-19) Exposure StatusThis section is dedicated to clarifying your current status as it relates to having, had exposure or suspicion of exposure to the Coronavirus (Covid-19). Please answer all of the questions below.Who was exposed to the virus? Myself Household Member Associate Date of suspected or actual exposure: MM slash DD slash YYYY Your Exposure Level: My client, household member or associate suspects they have the virus. My client, household member or associate has tested positive/been diagnosed w/the virus Myself or a household member is displaying some symptoms of virus and/or testing pending Myself or a household member have been tested for the virus and awaiting results. Select all that apply. IF you have tested positive and been diagnosed with the Coronavirus (Covid-19), please provide the diagnosis date below.Official Diagnosis Date: MM slash DD slash YYYY Describe setting and situation of suspected or actual exposure:Have you been to the Still Waters' office since being diagnosed, exposed or suspect exposure to the Coronavirus (COVID-19)? Yes No I can't remember. Describe all who you may have been face to face with since your exposure:Provide names of individuals, relationship to you and their contact information if available.If any symptoms are being experienced, please list and approximate onset of symptoms:Please list contact and relationship info. on who we may speak to on your behalf if more information is needed Δ
