Hello from your team at Lifeologie Fort Worth! 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!
Name *
Your answer
Email *
Your answer
Your therapist's name *
Your answer
Session date
Session time
Health check-in
Please fill out the following questions and tell us how you are :)
Have you had any of the following symptoms in the past week? (check all that apply) *
If yes, please supply details
Your answer
Have you traveled outside the country in the past month? *
If so, where?
Your answer
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? *
Are you immune-suppressed? *
Based on your answers, do you feel a remote session would be advisable? *
Please provide a contact phone number.
Your answer
Never submit passwords through Google Forms.
This form was created inside of Lifeologie counseing centers. Report Abuse