Template library · Intake forms
Insurance & Consent Intake template
Collect consent, policy acknowledgment, and coverage information.
Administrative intake for consent and coverage
- 15 fields across 3 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
Consent Items Reviewed
- Informed consent for treatmentTick box
- Confidentiality policy and limitsTick box
- Cancellation / no-show policyTick box
- Financial responsibility / insurance coverageTick box
- Telehealth consent (if applicable)Tick box
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
- 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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