Balance and fall prevention intake that captures mobility level up
The intake asks about recent falls or near-falls, current mobility level, and whether a doctor has recommended therapy, then collects a short gait video, so your staff sees exactly who needs a same-week slot versus a routine screening.
The exact intake your balance and fall prevention leads complete
This is the real 7-question guided intake for Balance and Fall Prevention — the same flow your customers finish before you ever pick up the phone.
What a qualified balance and fall prevention lead should tell you
Physical therapy evaluation and treatment aimed at reducing fall risk, typically triggered by a recent fall or near-fall, ongoing unsteadiness, or a mobility decline following surgery, hospitalization, or normal aging.
- Person Had Fall Or
- Best Describes Person'S Current
- Main Concern Prompting This
- This Request Being Made
- Doctor Recommended Physical Therapy
- Soon Would Like Therapy
- Person Able Travel In-Person
The questions your team needs answered
Every balance and fall prevention intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Has the person had a fall or a near-fall in the past six months? | A recent fall or near-fall is the strongest single indicator of ongoing fall risk, so it carries the heaviest weight in the intake. |
| Which best describes the person's current mobility? | Mobility level separates independent walkers from people who need hands-on assistance, which changes both the urgency and the staffing needed for the first appointment. |
| What is the main concern prompting this request? | Segments the lead so you can route, price, and prioritize it correctly. |
| Who is this request being made for? | Knowing whether the request is for the person themselves, a family member, or a professional caregiver's client tells staff who to actually speak with when confirming the appointment. |
| Has a doctor recommended physical therapy for this issue? | A physician referral signals a documented medical need and is weighted alongside fall history when deciding how quickly to reach out. |
| How soon would you like therapy sessions to begin? | Segments the lead so you can route, price, and prioritize it correctly. |
| Is the person able to travel to in-person appointments? | Whether the person can get to in-person sessions determines if they fit the clinic's standard appointment model or need an alternate care path before a slot is offered. |
How Cliont scores balance and fall prevention leads
Every answer is weighted automatically — no manual review required.
Value signals
- Person Had Fall Or: yes
- Walks independently, no aid
- Walks with a cane or walker
- Needs help from another person to walk
- Doctor Recommended Physical Therapy: yes
- Person Able Travel In-Person: yes
See the lead your team receives
Balance and Fall Prevention Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for balance and fall prevention workflows
| Cliont capability | Balance And Fall Prevention application |
|---|---|
| Video widget | Collects a short clip of the person walking so staff can see gait quality before the first visit, rather than relying on a self-reported mobility category alone. |
| Weighted scoring | Fall and near-fall history, current mobility level, and travel ability are weighted together so a recent fall combined with needing assistance to walk scores well above a preventive, no-incident inquiry. |
| Lead routing by requester | Separates who submitted the form (self, family member, or professional caregiver) so front-desk staff know who to call to confirm details and who the actual patient is. |
| CRM delivery | Sends fall history, mobility level, and doctor referral status straight to your CRM record so the front desk isn't re-asking basic risk questions on the intake call. |
Common balance and fall prevention lead scenarios
Recent fall, needs assistance
The person had a fall in the last six months and now needs help from another person to walk. This is the highest-priority mobility profile the intake flags, and doctor referral status is captured alongside it.
Preventive check, no incidents
No fall history, walks independently, and is just exploring options. The intake still records mobility level and referral status but the lead comes through as lower-urgency and exploratory rather than urgent.
Post-surgical recovery referral
Main concern is recovery after surgery or hospitalization, a doctor has already recommended therapy, and the requester wants to start as soon as possible. The referral answer and start-timeline pair together to move scheduling up.
Family member booking for parent
A family member submits the form for someone who walks with a cane or walker and had a recent near-fall. The intake separates who is filling it out from the actual patient's mobility answers so staff know who to call.
Caregiver inquiry, no travel
A professional caregiver requests care for a client who cannot travel to in-person appointments. That transportation limitation surfaces clearly so the clinic can decide how to handle it before booking a standard slot.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More physical therapy intake templates
Balance and Fall Prevention lead-intake FAQs
How does the intake tell a fall-recovery case apart from a preventive inquiry?
The main concern question separates a recent fall or injury, general unsteadiness, preventive interest with no incidents, and post-surgical recovery into distinct answers, so those cases don't all land in your inbox looking identical.
Can the form tell who actually needs the appointment when a family member fills it out?
Yes. The intake asks whether the request is for the person themselves, a family member, or a client a professional caregiver looks after, so your staff knows who to contact to confirm scheduling and consent.
Does the intake check whether a doctor already recommended physical therapy?
It does, with a direct yes/no question. That answer helps you gauge documented medical need and prioritize leads where a physician has already flagged the fall risk.
What happens if the person can't get to in-person sessions?
The intake asks directly whether the person can travel to in-person appointments. If not, that answer flags a transportation constraint before you offer them a slot they can't reasonably use.
How does mobility level affect how a lead is prioritized?
The intake distinguishes between walking independently, using a cane or walker, needing hands-on assistance from another person, or primarily using a wheelchair, since each of those needs a different first-visit setup.
Does this intake work for wheelchair users, or is it only for people who can walk?
The mobility question includes a wheelchair option, so those leads still come through and are visibly distinguished from ambulatory fall-risk cases rather than being forced into an ill-fitting category.
Turn balance and fall prevention visitors into qualified patients
Give every balance and fall prevention visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.