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You are here: Home / I Need Help With… / COVID-19 Information and Resources / COVID-19 Pre-Screening Questionnaire

COVID-19 Pre-Screening Questionnaire

Before arriving at your scheduled therapy appointment, please complete our COVID-19 pre-screening questionnaire.

COVID-19 Pre-Screening Questionnaire

Name of Business: Cohesive Therapy NYC
Industry: Mental Health
Address: 59 East 54th Street, Suite 92, New York, NY 10022
Contact Information: Tel: (347) 704-0632 or Email: info@cohesivetherapynyc.com
Owner/Manager of Business: Karen Conlon, LCSW

Please answer all of the following questions before each appointment:

Full Name *

First

Last

Email Address *

Phone Number *

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. For everyone's safety, our facility requires that everyone entering the building is wearing a mask in order to be allowed entry. Please ensure to be wearing a mask over your nose and mouth before entering the building. *

Yes, I understand.

Today's Date *

Your Appointment Date *

In the last 14 days, have you experienced Fever and/or Chills? *

Yes
No

In the last 14 days, have you experienced Cough? *

Yes
No

In the last 14 days, have you experienced Shortness of Breath and/or Difficulty Breathing? *

Yes
No

In the last 14 days, have you experienced Fatigue? *

Yes
No

In the last 14 days, have you experienced Muscle Aches and/or Body Aches? *

Yes
No

In the last 14 days, have you experienced Headache? *

Yes
No

In the last 14 days, have you experienced New Loss of Taste and/or New Loss of Smell? *

Yes
No

In the last 14 days, have you experienced Sore Throat? *

Yes
No

In the last 14 days, have you experienced Congestion and/or Runny Nose? *

Yes
No

In the last 14 days, have you experienced Nausea and/or Vomiting? *

Yes
No

In the last 14 days, have you experienced Diarrhea? *

Yes
No

In the last 14 days, have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19? *

Yes
No

In the last 14 days, have you hhave you had close contact with anyone who has travelled to any other states or any other country? *

Yes
No

In the last 14 days, have you visited any other states? *

Yes
No

If yes, list every state you have visited in the past 14 days.

In the last 14 days, have you visited any other countries? *

Yes
No

If yes, list every country you have visited in the past 14 days.

Please complete this questionnaire again if any of your answers change before your appointment. Cohesive Therapy NYC cannot guarantee the security of any information provided. Please only provide non-confidential information in transmitting this form or any information to this site by email. By using this form and communicating information to Cohesive Therapy NYC you understand that all communications will not be able to be considered confidential.

PLEASE ALSO SEE OUR BUILDING PROCEDURES

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Location

59 East 54th Street, Suite 92

New York, NY 10022

Contact Info

(347) 704-0632

info@cohesivetherapynyc.com

Specialties

Anxiety and Depression
Trauma and PTSD
Self-Growth and Improvement
Managing Chronic Illness
COVID-19 Information and Resources

Therapists

Karen Conlon, LCSW CCATP
Danielle DiCamillo, LCSW
Rachel Kaplan, LCSW
Frank Grazioli, LCSW

Services

Gut-Directed Hypnotherapy
Exposure Therapy
Cognitive Behavioral Therapy
Remote/Online Therapy Sessions
Frontline Worker Acute Care Program
Brainspotting
Clinical Consultation with Karen

The information included on this website is solely for educational purposes and is not intended to be a substitute for health care or medical treatment by a physician or other health care professional. Do not rely on any of the information for diagnosis or treatment. Should you have any questions, you should contact your health care provider. If you think you may have a medical or psychiatric emergency, call 911 immediately.