Returning Client Intake

Please complete this form prior to your appointment and be sure to hit ‘submit’. To protect your Health Information, only provide your initials, not your full name. There will still be a paper form in the waiting room for you, to let me know how you’re feeling at the time of you’re appointment and what your current goals are for our work.

Returning Client Intake Form

(to maintain privacy)
MM slash DD slash YYYY
Time of Appointment
:

COVID-19 SCREENING QUESTIONS:

If you answer yes to any of the symptom questions, you must reschedule your appointment to after you have been symptom free for 72 hours without medical intervention or medications. If you answer yes that you have been around someone with symptoms or diagnosed Covid-19, you must reschedule for at least 5 days after that exposure.
Have you had shortness of breath?
Have you had a fever?
Have you had a new or worsening cough?
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 5 days?*

HEALTH HISTORY AND CURRENT STATUS:

do not leave blank, type n/a if not applicable to you.

WAIVER, POLICIES AND FEES: