COVID-19 Risk Assessment

To keep everyone safe we ask that anyone who has a face-to-face appointment with us completes the following risk assessment prior to their assessment or therapy session.

Known COVID-19 symptoms include – fever, dry cough, tiredness, aches and pains, sore throat, diarrhoea, conjunctivitis, headache, loss of taste or smell, a rash on skin, or discolouration of fingers or toes, difficulty breathing or shortness of breath, chest pain or pressure, loss of speech or movement (World Health Organisation).

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Thank you for completing your COVID-19 form

Name

Date of Appointment (DD/MM/YYYY)

1. Do you have/have you had any symptoms of COVID-19 (see symptom list above) in the last 10 days?(required)

Yes

2. Have you or anyone in your household tested positive for COVID-19 in the last 10 days?(required)

Yes

3. The answers provided are true and correct to the best of my knowledge. I will notify Adélie Psychology should they change prior to my appointment.(required)

I agree