Client Intake and Kickoff Form

Form Instructions:
1. Please fill out all sections
2. Do not press “enter” to move to next box, press “tab”
3. For sections where you need to input information for multiple locations, there is an
“add” button at the bottom of the section for additional locations
4. Please press “submit” at the bottom of the form when complete

Section 1 – Organization Overview

Enter your organization’s full legal name.
If your team uses a short name or abbreviation (e.g., ‘Pine Street Clinic’ = ‘PSC’), please include it.
Select the category that best describes your organization.
Please list the main types of services your organization provides (e.g., primary care, pediatrics, urgent care, imaging, specialty consultations, lab testing). A few sentences or bullet points are fine.

Section 2 – Locations

How many physical office or clinic locations do you operate?

For each location, please provide: (click the "add" button below to populate fields for another location)

What do you call this location internally? (e.g., ‘Main Campus,’ ‘East Clinic’).
Full street address, city, state, and ZIP code.
Main phone line for this location.
List regular business hours (e.g., Mon–Fri 8am–5pm).

Section 3 – Call Center / Contact Center

Do you have a centralized call center or scheduling line?

(If Yes) Please provide details for each call center:

What do you call it internally? (e.g., ‘Main Scheduling Line’).
Where is this call center based?
List all inbound numbers for this center.
When is this call center open?
Approximate number of people handling calls.
A “queue” is a call waiting line for a specific purpose (e.g., “Referrals,” “Prescription Refills,” “Billing,” “Medical Records,” “Appointment Scheduling”). Example: Queue 1 – English, Spanish; Queue 2 – English, Portuguese.
Definition: A “team” is a group of agents with a unique workflow or skill set (e.g., “Imaging Scheduling Team,” “Nurse Triage Team”).
Example: “Prescription Refill Team backs up Appointment Scheduling when call volume is high.”
Definition: “Modality” refers to the type of service handled. Examples: X-ray scheduling, MRI scheduling, imaging results, family medicine, OB/GYN referrals.

Section 4 – Technology Setup

Name of your phone system provider (e.g., Cisco, Avaya, RingCentral, etc.).
Communication Platforms Used
Enter the name of your primary system (e.g., Epic, Cerner, Allscripts).
List any other important systems (e.g., scheduling, billing, patient portal, CRM).
Examples: OB/GYN, Primary Care, Radiology, Pharmacy, Behavioral Health, Dental, Billing, Medical Records, WIC, SNAP Benefits.
Example: “OB/GYN calls at Clinic A overflow to Clinic B if agents are unavailable.”
Hint: A “backline” is a direct, non-patient line for providers to reach staff quickly (often a hunt group ringing multiple phones).
Example: “Two front desk agents for check-in; two behind the desk for phones; nurse stations allow any nurse to answer from any phone.”
Hint: Are triage nurses dedicated full-time, or do they rotate between triage and other duties?

Section 4 – Skills, Proficiencies & Workflows

Do you use skill proficiencies for agents?
Hint: Skill proficiency = assigning skill levels for routing (e.g., Spanish Level 3, Billing Expert).
Can agents/nurses log in and work from any phone/workstation?
Do you use overflow and look-ahead routing between queues or departments?
Examples: “Pharmacy calls are only handled by pharmacy staff.” “Medical Records has its own building and only handles records requests.”

Section 6 – Patient Communication

How do patients primarily contact you?
Do you send appointment reminders?
Do you require call recording or quality monitoring?

Section 7 – Volumes & Metrics

(Number in minutes)

Section 8 – Key Contacts

Main point of contact for general communication.
Person responsible for IT, phones, or systems setup.
Person who handles billing and financial questions.

Section 9 – Additional Notes