In-Home LCSW Employee/ Client Covid Screening
Please answer the following questions before entering the office. If you answer YES to any of the following questions, please stay home.
Email address *
Full name *
Have you (and/or your child) experienced a fever of 100.4 or greater, a new cough, new loss of taste or smell or shortness of breath within the past ten days? *
In the past ten days have you (and/or your child) tested positive for Covid-19? *
To the best of your knowledge, have you (and/or your child) been in close contact with someone who tested positive for Covid-19? *
In the past 14 days, have you (and/or your child) traveled internationally or returned from a state identified by New York State as having widespread community transmission of Covid-19? *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy