Mandatory COVID-19 Screening for Face to Face Sessions

You must complete this screening questionnaire before each appointment. Creative Counseling and Studio reserves the right to cancel your appointment without the completion of this form prior to your session.

Please correct the errors described below.

Client Information

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. Please confirm today's date and the date of your appointment.

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Contact History

Travel History

Please complete this questionnaire again if any of your answers change before your appointment.

Did you answer yes to any questions?

If you answered YES to any of the questions above, contact Yasmin directly to discuss telehealth options until you or those around you are symptom free. Thank you.

Your information will be encrypted.