Use this form to screen individuals before and when they come in the office or require services.

  • MM slash DD slash YYYY
  • Above: Name of person that will receive services and is being screened.
  • Above: Fill if the Parent or Guardian is answering the questions on behalf of the Individual and will also be attending the session.
  • Above: List name of person asking the questions to the individual being screened.
  • Email of person doing the screening.

    Note: Positive responses to any of these questions would likely indicate a deeper discussion concerning whether or not Individual should proceed with treatment during this time.
    Individuals who are well but who have a sick family member at home should consider postponing elective treatment.