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Hello from Lifeologie Counseling! Your mental and physical health are important to us!
Help us help you!
In order to ensure continuity of care while providing safety for our clients and staff, we are asking you to complete and return this quick survey before your next appointment. Filling out this BRIEF form will help us ensure your health as well as the health of others in our offices. If you feel you are at risk or may have been exposed to COVID-19, we will arrange a session via phone or HIPAA-compliant e-portal!
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* Indicates required question
Name
*
Your answer
Email
*
Your answer
Your therapist's name
*
Your answer
Session date
MM
/
DD
/
YYYY
Session time
Time
:
AM
PM
Health check-in
Please fill out thee following questions and tell us how you are :)
Have you had any of the following symptoms in the past week? (check all that apply)
*
Sore throat or cough
Shortness of breath
I am experiencing NO symptoms
Fever above 100
Required
If yes, please supply details
Your answer
Have you traveled outside the country in the past month?
Yes
No
Clear selection
If so, where?
Your answer
Have you been in close physical contact with anyone who has traveled to China, South Korea, Japan, Iran, or Italy in the past month, who has experienced a high fever, coughing or shortness of breath?
*
No
Yes
Required
Are you immune-suppressed?
*
Yes
No
Based on your answers, do you feel a remote session would be advisable?
*
Yes, please contact me.
No, I am healthy and ready to go!
I'm not sure - please contact me
Required
Please provide a contact phone number.
Your answer
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