Wellness Check

Please indicate whether you are a client or employee.*

Therapy Type*

Purpose*

Date*

Check-In Time

:

Check-Out Time*

:

First Name*

Last Name*

Temperature*

Location*

Region of Illinois*

BCBA (Pennsylvania)*

BCBA (Massachusetts)*

BCBA (Oregon)*

BCBA (Michigan)*

Region of Virginia*

BCBA (Missouri)*

BCBA (Chicago)*

Have you, or anyone in your home experienced any of these symptoms in the past 72 hours that were NOT due to a pre-existing medical condition?*

Other Symptoms

If other, please explain.

Have you or anyone in your home been exposed to someone with Coronavirus (COVID-19) in the past 14 days?*

Have you or anyone in your home been exposed to someone showing Coronavirus (COVID-19) symptoms in the last 14 days?*

If exposed, has it been addressed and resolved?*

How many days have passed since you were exposured?*

Please provide the name of the county you live in.*

Have you or anyone in your home traveled domestically, or internationally, within the past 14 days?*

Date of Travel*