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 NameLast Name
Child Date of Birth:*

MonthDayYear
Date
Parent/Caregiver completing this form*

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

Parent/CaregiverChild being treated at TWSibling of child being treatedOther close family member
Date of Positive Covid Test*

MonthDayYear
Date
Services at TW*

Occupational TherapyPhysical TherapySpeech and Language TherapyTWISPP
Please list the name(s) of your therapist(s), if possible
Please list most recent treatment date at TW, if known

MonthDayYear
Date
Please mark the location(s) your child receives services:*

WashingtonGardena
Follow Up
Should be Empty: