THERAPIST RETURN TO WORK QUESTIONNAIRE 

As per section 4 or the Return to Work Protocol “Implementing the COVID-19 Prevention and Control Measures to Minimise risk to Workers” Malahide Counselling & Psychotherapy must issue a pre-return to work form for therapists to complete at least 3 days in advance of their return to work. This form seeks to confirm that each therapist, to the best of their knowledge, has no symptoms of COVID-19 and also confirm that they are not self-isolating or awaiting the results of a COVID-19 test. 

If a therapist answers Yes to any of the following questions they will be strongly advised to follow the medical advice they receive or seek medical advice before returning to work: 

THERAPIST RETURN TO WORK QUESTIONNAIRE	Y	N
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? Yes/No,
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? Yes/No,
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)? Yes/No,
Have you been advised by a doctor to self-isolate at this time? Yes/No,
Have you been advised by a doctor to cocoon at this time? Yes/No.

FORM REQUIRED TO BE SIGNED BY ALL CLIENTS

CONSENT AND SIGNATURE REQUIRED FROM ALL CLIENTS.

To ensure the Safety & Health of all people interacting with Malahide Counselling & Psychotherapy, Clients must complete this declaration form prior to commencing their first therapy session on or after May 18th 2020. At any subsequent sessions your therapist will verify the answer you give below are still applicable

If you indicate to us you have symptoms of COVID-19 OR you have been abroad in the last 14 days with exception to Northern Ireland you should not be attending the practice. Where this is the case, you will be asked to leave the premises and advised to seek professional medical help/assistance.

1	Have you visited any of the countries outside Ireland excluding Northern Ireland?	Yes / No
2	Are you suffering any flu like symptoms/symptoms of coronavirus covid-19?	Yes / No
3	Are you experiencing any difficulty in breathing, shortness of breath?	Yes / No
4	Are you experiencing any fever like/Temperature symptoms?	Yes / No
5	Did you consult a Doctor or other medical practitioner?	Yes / No
6	How are you feeling Healthwise?	Well / Unwell
7	Have you been in contact with someone who has visited an affected region in the past 14 days?	Yes / No

NOTE: When attending the Practice, please adhere to our on-site standard procedures regarding infection control, i.e. hand washing/hand sanitising and general coughing/sneezing etiquette. 

In the event that Malahide Counselling & Psychotherapy are asked to provide details of persons who have visited their premises for the purposes of Contact Tracing, I consent to the release of my ‘First Name & Mobile Number’ to the requesting body/authority. 

Malahide Counselling & Psychotherapy will follow the HSE & NSAI protocols to keep it’s Clients and Therapists as safe as possible from Covid 19 and will not be held responsible by any individual or group should they contract the virus.  

• Please tick the box to show you agree.

Client Signature: ________________________________Date:_______________________

Protocol to be followed by Therapists in the event of a Suspected Case of COVID-19 in the Workplace 

While a therapist or client should not attend the Practice work if displaying any symptoms of COVID-19, the following steps outline how to deal with a suspected case that may arise during the course of work. 

• In the event you or your client suddenly feel ill you must treat this as a suspected case of Covid 19.
• Each therapist will be in charge of their own situation but may enlist the assistance of another therapist is required.
• Room 2 will be used as an ‘isolation’ area. 
• Provide the following:
  • Ventilation, i.e. via a window, 
  • Tissues, hand sanitiser, disinfectant and/or wipes,
  •  Gloves, masks for all those dealing with the situation
  • Ensure the person presenting with symptoms puts on a mask. 
  • Waste bags.  
• Asess whether the unwell individual can immediately be directed to go home and call their doctor and continue self-isolation at home.
• Facilitate the person presenting with symptoms remaining in isolation if they cannot immediately go home and facilitate them calling their doctor.
• Ask the person suspected of having the virus to avoid touching people, surfaces and objects.
•  Advice should be given to the person presenting with symptoms to cover their mouth and nose with the disposable tissue provided when they cough or sneeze and put the tissue in the waste bag provided. 
• Arrange transport home or to hospital for medical assessment. 
• Public transport of any kind should not be used. 
• Carry out an assessment of the incident which will form part of determining follow-up actions and recovery.
• The areas involved in the incident should be cleaned and disinfected [using one of the ‘fogging’ machines] as soon a possible and before anyone else is allowed to enter the premises
• Provide advice and assistance if contacted by the HSE. 

Additional advice on dealing with a suspected case is available from the NSAI: 

https://www.nsai.ie/images/uploads/general/NSAI-Guidelines-for-COVID-19-2020-04-09.pdf 

The best way to prevent person-to-person spread of COVID-19 is to use proper hand hygiene and respiratory etiquette and practice physical distancing.