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In-Person Screening Questions

This form is to be completed 15 minutes prior to each in-person session. 

Have you knowingly come into contact with someone with COVID-19 in the past 72 hours?
Are you awaiting the results of a COVID test or have had a positive COVID test in the past 72 hours?
Have you or anyone in your household experienced any of the following symptoms: fever, chills, sore throat, cough, chest congestion, nausea, shortness of breath, or loss of smell in the past 72 hours?
Have you travelled to a CDC specified hot zone in the past 10 days?

Thank you for submitting.  The form has been received and will be reviewed by your therapist before your session. 

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