Template library · Intake forms
Holistic Wellness Intake template
Rate your current satisfaction across the following areas of wellbeing.
Whole-person wellness intake across life domains
- 16 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Domains of Wellness
- 1. Physical healthChoice
- 2. Emotional wellbeingChoice
- 3. Social connectionChoice
- 4. Financial wellbeingChoice
- 5. Career / purpose satisfactionChoice
- 6. Physical environmentChoice
- 7. Spiritual / meaning-based fulfillmentChoice
Goals
- Top priorities for improving wellbeing over the next 3 monthsText
Signatures
- Client SignatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
Spend less time on admin, more time with clients
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