COVID-19

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Due to the ongoing COVID-2019 Pandemic, all clients are required to complete this form prior to engaging in services. Participation in services is subject to approval upon completion of this form. Effective immediately, all participants are required to wear cloth face coverings while engaging in both individual or small group sessions, temperature taken and utilize hand disinfectant upon entering our offices. These guidelines are being observed to ensure our clients and staff as well as their loved one's remain safe and healthy.

YES          NO

Has the client  received a COVID-19 Vaccine

IF YES, Which Vaccine and When ____________________________

YES          NO

Has the client or anyone in your household traveled outside the US in the past 2 weeks (14 

days)?

IF YES, WHERE  ____________________________

YES          NO

Has the client or anyone in your household traveled outside of Missouri in the past 2 weeks (14 days)?

IF YES, WHERE_____________________________                                                  

YES          NO

In the past 2 weeks (14 days) has the client or anyone in your household had contact with any person suspected to have contracted coronavirus (COVID-19)? Including being tested for COVID-19 and/or being in self isolation for COVID-19?

YES          NO

In the past 2 weeks (14 days) has the client or anyone in your household had contact with any person confirmed to have contracted coronavirus (COVID-19)?

YES          NO

Has the client currently been exposed to someone with flu-like symptoms (cough, shortness of breath or fever)?

HAS THE CLIENT EXPERIENCED ANY OF THE SYMPTOMS BELOW IN THE LAST 72 HOURS?

FEVER

COUGHING 

SORE THROAT

DIFFICULTY BREATHING 

SHORTNESS OF BREATH OR WHEEZING 

MUSCLE ACHES

STOMACH PAINS VOMITING OR DIARRHEA 

PINK EYE/ RED EYES RASH

FATIGUE OR FEELING UNWELL

                                               Novel Coronavirus (COVID-19)

                                      Center for Disease Control and Prevention

• Wear a mask that covers your nose and mouth to help protect yourself and others.
• Stay 6 feet apart from others who don’t live with you.
• Get a COVID-19 vaccine when it is available to you.
• Avoid crowds and poorly ventilated indoor spaces.
• Wash your hands often with soap and water. Use hand sanitizer if soap and water aren’t available.

• Visit your state, tribal, local, and territorial health department’s website to look for the latest local information on testing.
• Talk to your healthcare provider about getting tested. You and your healthcare provider might consider either in-person testing, an at-home collection kit, or an at-home test.
• If you have symptoms of COVID-19, or if you have not been vaccinated and have been in close contact with someone with COVID-19, it is still important to stay home even if you are not tested.

The most common symptoms of COVID-19 are

List of Most Common Symptoms

• Fever
• Cough
• Headaches
• Fatigue
• Muscle or body aches
• Loss of taste or smell
• Sore throat
• Nausea
• Diarrhea

Other symptoms are signs of serious illness. If someone has trouble breathing, chest pain or pressure, or difficulty staying awake, get medical care immediately.

• Stay home except to get medical care. If you have symptoms of COVID-19, contact your healthcare provider and get tested.
• Isolate yourself from others, including those living in your household, to prevent spread to them and the people that they may have contact with, like grandparents.
• Call 911 if you are having emergency warning signs, like trouble breathing, pain or pressure in chest.