Hello from your team at Lifeologie Dallas! 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 in office appointment, there is no need to fill out the form if you are already set up for a virtual session.
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 virtual session!
Your therapist's name
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)
Fever above 100 or chills
Sore throat or dry cough
Shortness of breath or difficulty breathing
New loss of taste or smell
I am experiencing NO symptoms
If yes, please supply details
Have you traveled outside the country in the past month?
If so, where?
Are you immune-suppressed?
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
Please provide a contact phone number if you wish to be contacted.
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This form was created inside of Lifeologie counseing centers.