COVID Questionnaire

With recent spike in COVID cases in the state of Alabama and the Birmingham ares, effective August 4, 2021 Bevill and Associates Behavioral Health is implementing the following COVID policy. Prior to any client entering our office the following questionnaire must be completed. If an individual has not been vaccinated for COVID they will be required to wear a mask prior to entering the office or reschedule their appointment to a online video session. The safety of our clients, staff, families and visitors remain Bevill and Associates Behavioral Health overriding priority. (optional)

First Name

Last Name

Date of Birth

Appointment Date and Time

Self-Declaration

Have You Received the COVID Vaccination?

IF YOU RESPOND NO, YOU WILL REQUIRED TO WEAR A MASK OR RESCHEDULE YOUR APPOINTMENT TO A ONLINE VIDEO APPOINTMENT

Yes

Have you had contact with anyone with confirmed COVID-19 in the last 14 days?

Yes

Have you had any of these symptoms in the 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)

Yes

Have you had a fever greater than 100 in the last 24 hours?

All clients are subject to a temperature check prior to appointment

Yes

By signing this questionnaire I attest that my response to all questions are accurate and truthful.

Electronic Signature

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law