COVID-19 Screening - Mental Health Counseling and Therapy

All visitors are required to complete a pre-visit screening.

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Date
MM slash DD slash YYYY
Who is your counselor?*
Client Name*
First Last
Email Address*
Phone
Have you experienced any of the following symptoms in the last 48 hours?*
- Fever or chills
- Cough
- Shortness of breath
- Muscle aches
- Sore throat
- Yes
- No
Within the past 14 days, have you been in close physical contact (6ft or less) with anyone known to have COVID-19 or with symptoms consistent with COVID-19?*
(This includes a period of 15 minutes or longer while not wearing protective PPE, including a face mask)
- Yes
- No
Are you under current quarantine or isolation recommendations by any health professional (and have NOT already reported)?*
- Yes
- No
Are you currently waiting on the results of a COVID-19 test?*
- Yes
- No
Signature*
Type your name below to sign this document.
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Name
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