Template Formulaires de contact Modèle de formulaire d’information sur le client

Modèle de formulaire d’information sur le client

Modèle de formulaire d’information sur le client

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Client Information Form Template

This client details form collects a focused set of questions to gather information from your clients. It is suitable for use across industries — from restaurants to other service businesses — and can be tailored by editing fields, adding logos or images, and adjusting the design. Be sure your privacy policy is clear before clients submit the form. You can share the form with a link to collect responses, then view results and statistics instantly. Customize questions, fonts and colours, or add widgets to capture information in different ways. If you connect the form to other services (such as cloud storage or databases) you can send responses automatically and review them using form tables or report tools.
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*
1.
I have read the privacy policy and consent to your use of my personal data for:[Cases à cocher]
providing therapy
contacting me between sessions
processing payments and keeping records
*
2.
Signature (type your name if submitting online)
*
3.
Date of completion
*
4.
First name and surname
*
5.
Address (including postcode)
*
6.
Email address
*
7.
Best telephone number to reach you
*
8.
May I leave a message at that number?
Yes
No
*
9.
Name and telephone number of someone to contact in an emergency
*
10.
Which medical practice are you registered with?
11.
How did you hear about my service?
*
12.
Have you previously received any form of psychological therapy (e.g., psychotherapy, counselling)?[Cases à cocher]
Yes
No
Unsure
*
13.
Have you ever been diagnosed with any of the following? (Please tick all that apply)[Cases à cocher]
a psychosis, personality disorder or learning difficulty
type 1 diabetes
epilepsy
an eating disorder that required medical attention
other long-term health issues (physical or psychological)
none of the above
*
14.
Are you currently taking any prescription medication?[Cases à cocher]
Yes
No
*
15.
Have you ever had suicidal thoughts or attempted to harm yourself?[Cases à cocher]
Yes
No
*
16.
How would you rate your current sleep habits?
Poor
Variable
Good
Very good
*
17.
Who lives in your household? (Please list names, relationship to you, and ages if under 18)
*
18.
Which of the following best describes your current situation?
Full-time employed
Part-time employed
Homemaker
Retired
Other
*
19.
What do you do for enjoyment or to relax?
*
20.
How would you describe the healthiness of your diet?
Not healthy
Generally healthy
Very healthy
*
21.
What is your smoking status?
Never smoked
Former smoker
Currently smoke
*
22.
Have you ever used recreational drugs?
Never
More than a year ago
Less than a year ago
Unsure
*
23.
How often do you drink alcohol?
*
24.
What exercise do you usually do in an average week?
*
25.
How would you rate your current stress levels?
High
Manageable
Variable
Low
*
26.
How good is the support you receive from family and friends?
Excellent
Good
Adequate
Poor
None
*
27.
Have there been any major changes in your life over the last 12–18 months (e.g., home, work, family)?
Yes
No
*
28.
Do you have any fears or phobias (other than the issue you are consulting me about)?
Yes
No
*
29.
What are your goals for therapy?
30.
If you have more than one goal, which is the most important?
*
31.
I will ask you to listen to an audio regularly after appointments. How would you prefer to receive it?
Download
USB/memory stick
CD
32.
If there is any additional information you would like to include that did not fit elsewhere on the form, please add it here.
*
33.
Agreement
I have read and agree to these terms and conditions
*
34.
Signature (type your name)
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Template instructions
Le modèle de formulaire d’information sur le client recueille des informations essentielles sur le client pour toute entreprise ou service. Ce modèle gratuit simplifie l’admission en recueillant des informations personnelles, de contact, médicales et de consentement.

Le formulaire comprend des champs pour le nom, l’adresse, l’adresse e-mail, le téléphone, le contact d’urgence, le médecin généraliste ou le cabinet médical, les médicaments actuels et l’historique du diagnostic. Il pose également des questions sur le mode de vie, le sommeil, la consommation de substances, le stress, les objectifs ménagers et thérapeutiques, ainsi que les cases à cocher du consentement, la signature et la date.

Adapté aux cliniques, thérapeutes, salons, restaurants et autres entreprises, le modèle est entièrement personnalisable. Ajustez l’image de marque, les polices et les questions, ajoutez votre logo, activez les intégrations et exportez les réponses vers des outils tels que Google Drive ou Airtable. Vous pouvez activer les notifications par e-mail, la logique conditionnelle et les flux de travail automatisés pour simplifier le suivi, la prise de rendez-vous, les rappels et la gestion des clients pour des opérations de cabinet et des rapports efficaces.

Cliquez sur « Utiliser ce modèle » pour commencer à personnaliser et à recueillir des informations sur les clients dès aujourd’hui.

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