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Bear Creek Counseling Center

Covid-19 Patient Health Screening Form

Please take a moment to fill out your Covid-19 Patient Health Screening Form prior to your scheduled appointment with Bear Creek Counseling Center. A new form is required for every appointment with us until further notice. Thank you!

In the past 14 days, have you traveled to a foreign country or been in close contact (within 6 feet) with a person who has returned from a foreign country within the past 14 days?
In the past 14 days, have you traveled outside of your hometown within the United States without following the recommendations or guidelines of the CDC (e.g., wearing personal protective equipment such as facemasks and/or adhering to social distancing standards)?
Do you currently have (or have you had in the past 14 days) any of the following symptoms: Fever, Chills, Cough, Headache, Sore Throat, Congestion or Runny Nose, Nausea or Vomiting, Shortness of Breath or Difficulty Breathing, Loss of Smell or Taste, Unusual Fatigue, Diarrhea, Muscle or Body Aches?
In the past 14 days, have you been in contact (within six feet) of a person with possible Coronavirus or has a confirmed diagnosis of COVID-19, is under investigation for COVID-19, or is ill with a respiratory illness?

Thank you for submitting!

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