COVID-19 Questionnaire Form
South Central Crisis Service
On-Call Clinician:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
*
Hour Minutes
AM
PM
AM/PM Option
Client Name:
*
First Name
Last Name
Age:
*
If unknown, enter "00."
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If unknown, enter "01-01-1000."
Please ask the following questions to determine correct procedure:
1. Do you have a fever, chills, headache, sore throat, new loss of taste of smell, or muscle pain, or believe you have been exposed to COVID-19?
*
Yes
No
N/A
2. Have you traveled outside of the United States or to areas within the United States that have experienced a high community spread in the past two weeks?
*
Yes
No
N/A
3. Have you had close contact in the past two weeks with a person who has been confirmed to have COVID-19?
*
Yes
No
N/A
4. Are you a health care worker and have had close contact with a person in the past two weeks who has suspected or confirmed COVID-19?
*
Yes
No
N/A
5. Have you been advised to stay home by a medical professional due to illness that might be COVID-19?
*
Yes
No
N/A
Clinician Signature:
*
Agency receiving form:
*
Please Select
BHcare Shoreline
BHcare Valley
Bridges Healthcare, Inc.
Clifford Beers
Connecticut Mental Health Center
Fellowship Place
West Haven Mental Health Center
Yale Behavioral Services at Hamden
Out of Catchment Area-jhagelston
Submit
Should be Empty: