COVID Screening Form FFCP

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FFCP is committed to the safety of our staff, clients, and families. This form must be completed prior to in-person sessions. This form does not need to be completed more than once per week.

Questions or need translation please call 240-304-3327

Email *

Clinicican Name *

Have you had any of the following symptoms during the last week: cough, shortness of breath, problems breathing, new onset loss of taste or smell, fever of 100.4 degrees or higher, chills, muscle aches, sore throat, headache, nausea, vomiting, diarrhea, fatigue, congestion, or runny nose? *

Yes

In the past week has anyone in the home been diagnosed with COVID-19, waiting for a COVID test result, or tested positive for COVID? *

Yes

In the past week have you (client) had close contact with anyone diagnosed with COVID-19 (close contact is being within 6 feet of someone with covid for at least 15 minutes). *

Yes

If you answered NO to all of the above questions an in-person therapy session is allowed. If you answered YES to ANY of the questions the therapy session must be conducted over telehealth.

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