Insomnia intake that asks what your team actually needs to know
Patients report how long they've struggled to sleep, whether it's affecting daytime mood or work, and what they've already tried, along with a sleep diary, so your team can prioritize appointments before booking a slot the patient doesn't qualify for.
The exact intake your insomnia evaluation leads complete
This is the real 5-question guided intake for Insomnia Evaluation — the same flow your customers finish before you ever pick up the phone.
What a qualified insomnia evaluation lead should tell you
A clinical intake for patients reporting ongoing trouble falling asleep, staying asleep, or waking too early, gathering duration, daytime impact, and prior treatment attempts so the clinician can prioritize the visit.
- Long Have Had Trouble
- Sleep Difficulty Best Describes
- Lack Sleep Affect Daytime
- Previously Tried Any Treatment
- Use Any Substances Close
The questions your team needs answered
Every insomnia evaluation intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| How long have you had trouble sleeping? | Sleep trouble lasting more than three months carries the highest weight because it meets the clinical threshold for chronic insomnia rather than a short-lived episode. |
| Which sleep difficulty best describes your main problem? | Identifying whether the main problem is falling asleep, staying asleep, waking early, or non-restorative sleep gives the clinician a starting point without affecting the score. |
| Does the lack of sleep affect your daytime functioning, such as work or mood? | A yes answer on daytime functional impairment carries the highest weight in the catalog because it signals the sleep problem is clinically significant, not just an occasional annoyance. |
| Have you previously tried any treatment or strategy for your sleep problem? | Knowing whether the patient already tried a treatment or strategy helps the clinician gauge if a first-line approach failed, which can change what type of appointment is needed. |
| Do you currently use any substances close to bedtime, such as caffeine or alcohol? | Reporting caffeine or alcohol use close to bedtime flags a possible behavioral contributor the clinician may want to address before ordering further testing. |
How Cliont scores insomnia evaluation leads
Every answer is weighted automatically — no manual review required.
Value signals
- Less than 2 weeks
- 2 weeks to 3 months
- More than 3 months
- Lack Sleep Affect Daytime: yes
See the lead your team receives
Insomnia Evaluation 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 insomnia evaluation workflows
| Cliont capability | Insomnia Evaluation application |
|---|---|
| Weighted scoring engine | Combines the duration of sleep trouble and daytime functional impact answers to separate chronic, clinically significant insomnia from short-term or low-impact cases. |
| Non-scored context fields | Captures prior treatment attempts and bedtime substance use as clinical context for the visit without letting them skew the priority score. |
| CRM routing | Sends only patients meeting the duration and daytime-impact thresholds to your CRM as qualified, reducing appointments booked for patients who may not need a full evaluation yet. |
| Structured symptom categorization | Uses the sleep difficulty type (falling asleep, staying asleep, waking early, non-restorative) to give the clinician a starting point without complicating the score. |
Common insomnia evaluation lead scenarios
Chronic insomnia with daytime impairment
Sleep trouble has lasted more than three months and is affecting work or mood, matching the two highest-weighted answers in the intake and warranting a prompt appointment.
New sleep trouble, minimal impact
Symptoms started less than two weeks ago and daytime functioning isn't affected yet, so the intake surfaces this as a case that may resolve without a specialist visit.
Already tried self-help strategies
The patient answers yes to previously trying a treatment or strategy, signaling that first-line behavioral approaches have already failed and a more clinical evaluation is likely needed.
Sleep hygiene factors present
The patient reports caffeine or alcohol use close to bedtime, which the intake captures separately from the scored questions so the clinician can weigh a behavioral contributor before ordering further testing.
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 sleep medicine intake templates
Insomnia Evaluation lead-intake FAQs
How does the insomnia intake differ from the Sleep Apnea Evaluation form?
This intake focuses on sleep-onset and sleep-maintenance symptoms, such as which type of difficulty the patient has (falling asleep, staying asleep, waking early, or non-restorative sleep), rather than breathing-pattern questions used in the Sleep Apnea Evaluation.
Why does the duration of sleep trouble carry so much weight in the score?
Sleep difficulty lasting more than three months is weighted highest because it meets the clinical threshold typically used to define chronic insomnia, versus a shorter episode that may resolve on its own.
Does the intake ask what the patient has already tried?
Yes, patients answer whether they've previously tried a treatment or strategy for their sleep problem, which helps the clinician gauge if a first-line approach already failed before the visit.
What happens if a patient reports caffeine or alcohol use near bedtime?
That answer is captured for clinical context rather than scored, so the clinician sees a possible behavioral contributor without it lowering the patient's overall lead priority.
Can this intake flag patients who don't yet need an insomnia specialist?
Yes, patients reporting recent, short-term sleep trouble with no daytime functional impact score lower, which helps your team avoid booking a specialist slot for a case that may not need one yet.
Is this form the same one used for Daytime Sleepiness patients?
No, Daytime Sleepiness is a separate sibling subservice with its own intake; this form is specific to sleep-onset and sleep-maintenance complaints.
Turn insomnia evaluation visitors into qualified patients
Give every insomnia evaluation visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.