SLN COVID-19 Self Assessment Questionnaire

We ask that for your safety and the safety of our clients, staff and clinical space, that you please fill out this form to the best of your ability, no more than 24 hours prior to attending your appointment.

We thank you for your time and attention to this self-assessment tool.

* Required

Please choose all that apply
Please note, answering YES does not prevent you from attending your scheduled appointment.
Please note, answering YES does not prevent you from attending your scheduled appointment.

CORONAVIRUS (COVID-19): The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is extremely contagious. The Speech Language Network has put in place preventative measures to reduce the spread of COVID-19; however, The Speech Language Network cannot guarantee that you or your child will not become infected with COVID-19. Furthermore, the client/family and therapist will collaboratively decide best PPE implementation for the client’s specific needs. By checking yes, you acknowledge you are aware of the risks, dangers and hazards, and that you are participating in therapy services at the Speech Language Network. Further details of enhanced protocols and guidelines to ensure the safety of our staff and can be found at www.thesln.com/clinic-policies .