COVID REPORTING FORM

COVID REPORTING FORM
We have created this form for parents/caregivers to report directly to the owners of Therapy West, Inc if their child tests positive for COVID-19.

If your child has tested positive, please complete the form below. Thank you.
Child Name *

First Name Last Name
Child Date of Birth: *

Month Day Year
Date
Parent/Caregiver completing this form *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Who tested positive: *

Parent/Caregiver Child being treated at TW Sibling of child being treated Other close family member
Date of Positive Covid Test *

Month Day Year
Date
Services at TW *

Occupational Therapy Physical Therapy Speech and Language Therapy TWISPP
Please list the name(s) of your therapist(s), if possible
Please list most recent treatment date at TW, if known

Month Day Year
Date
Please mark the location(s) your child receives services: *

Washington Gardena
Follow Up
Should be Empty: