Template Biểu mẫu liên hệ Mẫu biểu mẫu thông tin khách hàng

Mẫu biểu mẫu thông tin khách hàng

Mẫu biểu mẫu thông tin khách hàng

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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:[Hộp kiểm]
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)?[Hộp kiểm]
Yes
No
Unsure
*
13.
Have you ever been diagnosed with any of the following? (Please tick all that apply)[Hộp kiểm]
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?[Hộp kiểm]
Yes
No
*
15.
Have you ever had suicidal thoughts or attempted to harm yourself?[Hộp kiểm]
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
Mẫu biểu mẫu thông tin khách hàng thu thập thông tin khách hàng cần thiết cho bất kỳ doanh nghiệp hoặc dịch vụ nào. Mẫu miễn phí này hợp lý hóa việc tiếp nhận bằng cách thu thập thông tin cá nhân, liên hệ, y tế và sự đồng ý.

Biểu mẫu bao gồm các trường tên, địa chỉ, email, điện thoại, liên hệ khẩn cấp, bác sĩ đa khoa hoặc thực hành y tế, thuốc hiện tại và tiền sử chẩn đoán. Nó cũng hỏi về lối sống, giấc ngủ, sử dụng chất kích thích, căng thẳng, mục tiêu gia đình và trị liệu, cùng với các hộp kiểm đồng ý, chữ ký và ngày tháng.

Thích hợp cho phòng khám, nhà trị liệu, thẩm mỹ viện, nhà hàng và các doanh nghiệp khác, mẫu hoàn toàn có thể tùy chỉnh. Điều chỉnh thương hiệu, phông chữ và câu hỏi, thêm logo của bạn, bật tích hợp và xuất câu trả lời sang các công cụ như Google Drive hoặc Airtable. Bạn có thể bật thông báo qua email, logic có điều kiện và quy trình làm việc tự động để đơn giản hóa việc theo dõi, lên lịch cuộc hẹn, nhắc nhở và quản lý khách hàng để hoạt động thực hành và báo cáo hiệu quả.

Nhấp vào "Sử dụng mẫu này" để bắt đầu tùy chỉnh và thu thập thông tin khách hàng ngay hôm nay.

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