Today you are one step closer to a new you where you feel empowered and on a positive path to growth and well-being.

  • Counseling Services
    • Individual Counseling
    • Couples and Relationship Counseling
    • Adolescence – Teenage Counseling
    • Family Counseling
    • Addiction Counseling
    • Forensic Counseling
    • Online – Video Counseling
    • Group Therapy
  • Online Appointment Scheduling
  • Our Practice
    • Covid-19 Response
    • Bevill and Associates Clinical Team
    • Employment Opportunities at Bevill and Associates Behavioral Health
  • Forms and Practice Information
    • Client Portal
    • New Client – Intake Forms
    • Release of Confidential Information
    • Referral Form
    • Fees and Insurance
    • Contact Us
    • Directions To Our Office
    • Your Privacy
  • 72 Hour Appointment Promise
  • Resources
    • Common Questions
    • The Source To Healing and Hope Blog
    • Resource Videos
    • Client Education & Resources
    • Books Resources
    • Assessments
    • Accountability & Filtering Software
    • Current News in Psychology

COVID -19 Pre Appointment Questionnaire and Attestment

The safety of our clients, staff, families and visitors remain Bevill and Associates Behavioral Health overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads. Only clients with scheduled appointments are permitted into our office. We ask that client 14 yrs of and older enter the office and one under the age of 14 years of age will be allowed to be accompanied by one adult family member. To prevent the spread of COVID-19 and reduce the potential risk of exposure to other clients and our staff we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in the office.

Clients Name
Clients Date of Birth
Clients appointment date and time

Self-Declaration

I attest that my response to all questions are accurate and truthful. By signing this questionnaire I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering the offices of Bevill and Associates Behavioral Health that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Bevill and Associates Behavioral Health may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Bevill and Associates Behavioral Health employees, clients and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my counseling appointment (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless the Bevill and Associates Behavioral Health , its employees, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind.

By typing your name you are providing electronic signature.

Make an Appointment: (205) 610-9319 | info@bevillandassociatesllc.com

This website and its content has been prepared by Bevill and Associates LLC for general informational purposes only and does not constitute personal medical or mental health advice.

If you think you may have a medical or mental health emergency, please call 911. Viewing the information on this website is not intended to create and does not constitute a therapeutic relationship.

© Copyright 2017, Bevill and Associates LLC All Rights Reserved

Privacy Policy | Website by Brighter Vision

  • Counseling Services
    • Individual Counseling
    • Couples and Relationship Counseling
    • Adolescence – Teenage Counseling
    • Family Counseling
    • Addiction Counseling
    • Forensic Counseling
    • Online – Video Counseling
    • Group Therapy
  • Online Appointment Scheduling
  • Our Practice
    • Covid-19 Response
    • Bevill and Associates Clinical Team
    • Employment Opportunities at Bevill and Associates Behavioral Health
  • Forms and Practice Information
    • Client Portal
    • New Client – Intake Forms
    • Release of Confidential Information
    • Referral Form
    • Fees and Insurance
    • Contact Us
    • Directions To Our Office
    • Your Privacy
  • 72 Hour Appointment Promise
  • Resources
    • Common Questions
    • The Source To Healing and Hope Blog
    • Resource Videos
    • Client Education & Resources
    • Books Resources
    • Assessments
    • Accountability & Filtering Software
    • Current News in Psychology
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