Mark Dove Ad Dip PC, Dip Hyp CS, MBACP, MNCS (Accred)

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Covid-19 Risk Questionnaire for Clients

Covid-19 Risk Questionnaire for Clients

(all questions require a ‘yes’ or ‘no’ answer)

Name*
First Last
Phone*
Email*
Have you considered online therapy as a suitable alternative to face to face therapy?*
- Yes
- No
If you were to have a remote session either online or via the telephone, do you have somewhere in your home environment where you can talk confidentially and without interruption?*
- Yes
- No
Are you now or have you in the last 14 days been suffering from any of the symptoms of Covid-19? (if in doubt, see the NHS website https://www.nhs.uk/conditions/coronavirus-covid-19/ )*
- Yes
- No
Are you in a shielding group? *
- Yes
- No
Is anyone in your household or anyone for whom you act as a carer in a shielding group? *
- Yes
- No
Has anyone else in your household had the symptoms of Covid-19 in the last 14 days? *
- Yes
- No
Have you or anyone else in your household tested positive for the symptoms of Covid-19 in the last 14 days? *
- Yes
- No
Do you have any pre-existing health problems for which either you are receiving treatment or taking medication? *
- Yes
- No
Do you work in a profession which means that you come into contact with people who are known to be suffering from Covid-19? *
- Yes
- No
Does your workplace implement social distancing? *
- Yes
- No
Will you be travelling to your appointment using public transport? *
- Yes
- No
Do you use public transport frequently? *
- Yes
- No
Would you be willing to wear a face mask at a counselling session? *
- Yes
- No
Would you be willing to wear gloves to a counselling session?*
- Yes
- No
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