In an effort to prioritize the safety of all clients and staff, OCP is implementing additional safety measures in response to COVID-19. Before each in-person (community-based or office-based) session, you will be asked the following health screening questions. Based on your answers, the clinician may need to reschedule to transition the session to Telehealth per safety policies and procedures.
Had any recent contacts tested positive for or been diagnosed with having COVID-19?
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Client
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Anyone in the household?
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If yes, when? Date
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If yes, when? Date
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Have/had a recent fever (defined as above 100.4 degrees)?
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Client
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Anyone in the household?
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Have a cough?
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Client
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Anyone in the household?
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Experiencing shortness of breath or trouble breathing?
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Client
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Anyone in the household?
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Experiencing persistent pain, pressure, or tightness in the chest?
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Client
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Anyone in the household?
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I understand that I will be asked these questions by an OCP clinician before each clinical session while COVID-19 precautions remain in place. I attest these answers are true to the best of my knowledge.
Caregiver’s Name:
Client's Name:
