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Services & Fees
Clinicans
Contact
And More...
Home
Services & Fees
Clinicans
Contact
And More...
Please sign in and answer this short survey…
Client Name
*
First Name
Last Name
Time of appointment
*
Hour
Minute
Second
AM
PM
Who are you here to see?
*
Select One
Cynthia Conseillant, LCSW
Danyell Johnson, LCSW
Munico Lopez, LCSW
Judith Mondesir, LCSW
Have you experienced cold like symptoms within the past 3 days?
*
Have you recently tested positive for Covid-19 within the last 7 days?
Yes
No
Have you recently tested positive for Covid-19 within the last 7 days?
*
Yes
No
DLJ Clinical Services continues to follow the Center for Disease Control (CDC) guidelines for social distancing, sanitizing, and face mask coverings. However, DLJ cannot control the spread of Covid-19 during in person appointments. By printing your name below, you agree to full responsibility for possible exposure or contact with Covid-19. [Print your full name]
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Thank you!
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