Attestation for COVID-19 Safety

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At the Maynard Counseling Center, we take your safety serious, and ask that you help us keep others in our offices safe, too. Please complete this form within the hour leading up to your appointment.

Client Name *

Client temperature within an hour of appointment was... *

Have you or anyone in your household tested positive for COVID-19? *

Yes

If yes, what is the date your SYMPTOMS began?

YYYY

If yes, what is the date you TESTED positive?

YYYY

Do you or anyone in your household currently have any of the following that is not explained by another medical condition (please check all that apply).

Fever

Cough

Shortness of breath or difficulty breathing

Chills

Muscle pain

Sore throat

New loss of taste or smell

Other:

Have you, or anyone in your immediate household, been in close contact with anyone confirmed or presumed positive for COVID-19 in the past 14 days? *

Close contact is defined as 1) Being within approximatey 6 ft of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case, OR 2) Having direct contact with infectious secretions of a COVID-19 case (e.g. being coughed on).

Yes

Have you, or anyone in your immediate household, been asked to quarantine (due to travel, illness, exposure) by state/county mandates/guidance, a health care practitioner, the CDC or DOH in the past 14 days? *

Yes

Did you, or anyone in your immediate household, travel internationally or travel on a cruise ship in the past 14 days? *

Yes

I attest the information provided is accurate and honest. *

Agree

Disagree

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