In-Person Therapy Safety Guidelines
Please complete this form to ensure a safe environment for in-person therapy sessions. Your responses help us maintain the highest safety standards.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Loss of taste or smell
None of the above
Have you been in close contact with anyone diagnosed with a contagious illness (e.g., COVID-19, flu) in the past 14 days?
*
Yes
No
What is your current vaccination status for COVID-19?
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Date of Completion
*
-
Month
-
Day
Year
Date
Submit
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