COVID-19 Self Screening Questionnaire AT

1
Regardless of vaccination status you must answer “NO” to all the pre-screening questions in this questionnaire in order to enter our physical location.

If you answer “YES” to any of the questions, DO NOT come enter the buildings. If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your therapist to attend a virtual session.
2
1) Have you had any of the following symptoms in the past 48 hours:* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle aches/pain
Headache
Sore throat
New loss of taste or smell
Sinus Pressure/Runny Nose
Diarrhea
Fever (usually 100.4 or higher)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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3
2) Are you isolating or quarantining because you tested positive for COVID-19? OR Are worried that you may be sick with COVID-19?
YESNO
4
Did you answered “Yes” to questions 1 OR 2?

DO NOT come in for your appointment, you will have to remain virtual for your sessions. Please contact your therapist immediately to have them send you a Google Meet link. They can also provide more information about when you will be eligible to return to in-person services.

ANSWERED NO? Please continue to next section.
5
3) In the last 14 days have you:* This field is required.
YesNo
YesNo
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Been in contact with someone who was diagnosed with COVID-19?
YesNo
YesNo
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6
If you answered “Yes” to any part of question two.

DO NOT come for an in-person session, email your therapist immediately after you complete the form.

If NO, by signing, I certify to the best of my knowledge; this information is accurate.
7
I am up to date on my COVID-19 vaccine.Up to date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. Fully vaccinated means a person has received their primary series of COVID-19 vaccines.
YESNO
8
Name* This field is required.As listed in your client record.
First Name
Last Name
9
Signature* This field is required.By signing you agree that everything is true to the best of your knowledge and if you develop any symptoms in the next 48 hours you will notify your therapist immediately.
Clear
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