Hello from your team at Lifeologie Oak Cliff! 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 appointment.

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 session via phone or HIPAA-compliant e-portal!
What is your name? *
Your therapist's name *
Session date
MM
/
DD
/
YYYY
Session time
Time
:
Health check-in
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) *
Required
Have you been in close physical contact with anyone who has had the following symptoms: fever above 100, shortness of breath, or sore throat or cough? *
Have you traveled outside the country in the past month? *
If so, where?
Have you been in close physical contact with anyone who has traveled to China, South Korea, Japan, Iran, or Italy in the past month, who has experienced a high fever, coughing or shortness of breath? *
Required
Do you believe your immune system is compromised in any way? *
Based on your answers, do you feel a telehealth session would be advisable? *
Required
Please provide a contact phone number. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Lifeologie counseing centers. Report Abuse