Template Moduli di contatto Modello di modulo informativo per il cliente

Modello di modulo informativo per il cliente

Modello di modulo informativo per il cliente

Create a survey from a ready-made template in 30 seconds. Choose a template, customize it, then share it and collect responses with ease.
4.7/5
on G2
500.000+
Surveys created
10.000+
Team users
Use This Template
✓ Free forever
✓ No Credit Card Required
✓ Unlimited surveys, questions, and responses
34
Questions
Use This Template

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.
wait loading
*
1.
I have read the privacy policy and consent to your use of my personal data for:[Domanda a scelta multipla]
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)?[Domanda a scelta multipla]
Yes
No
Unsure
*
13.
Have you ever been diagnosed with any of the following? (Please tick all that apply)[Domanda a scelta multipla]
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?[Domanda a scelta multipla]
Yes
No
*
15.
Have you ever had suicidal thoughts or attempted to harm yourself?[Domanda a scelta multipla]
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)
image result
Template instructions
Il modello di modulo informativo per il cliente raccoglie i dettagli essenziali del cliente per qualsiasi attività o servizio. Questo modello gratuito semplifica l'assunzione raccogliendo informazioni personali, di contatto, mediche e di consenso.

Il modulo include campi per nome, indirizzo, e-mail, telefono, contatto di emergenza, medico di base o studio medico, farmaci attuali e storia delle diagnosi. Chiede anche informazioni sullo stile di vita, il sonno, l'uso di sostanze, lo stress, gli obiettivi domestici e terapeutici, oltre alle caselle di controllo del consenso, alla firma e alla data.

Adatto a cliniche, terapisti, saloni, ristoranti e altre attività, il modello è completamente personalizzabile. Regola il branding, i caratteri e le domande, aggiungi il tuo logo, abilita le integrazioni ed esporta le risposte su strumenti come Google Drive o Airtable. È possibile abilitare le notifiche e-mail, la logica condizionale e i flussi di lavoro automatizzati per semplificare il follow-up, la pianificazione degli appuntamenti, i promemoria e la gestione dei clienti per operazioni di studio e reportistica efficienti.

Fai clic su "Usa questo modello" per iniziare a personalizzare e raccogliere le informazioni sui clienti oggi stesso.

Get Started in 3 Simple Steps

1

Use This Template

Click "Use This Template" to open it in SurveyMars. You can preview and test it without signing up.

2

Customize Your Survey

Edit questions, upload your logo, and match the design to your brand. Create professional surveys with no technical skills required.

3

Share & Collect Responses

Share by link, QR code, or embed it on your website. Responses appear in your dashboard as soon as they come in.

What Our Users Say

Trusted by users worldwide

View More G2 Reviews
Related Templates
Modello di modulo per Address Collect
View Template ➝
Modello di modulo di domanda FAQ
View Template ➝
Modello di Richiesta Sito Web Archiviato
View Template ➝
FAI UNA DOMANDA Modello
View Template ➝
View All Templates