Whole Health Wellness Survey

This field is for validation purposes and should be left unchanged.

Patient Name(Required)

First Name Last Name

Date of Birth

Email(Required)

Phone(Required)

Purpose

WML Wellness is a Whole Health Wellness company offering an integrated approach to wellness, coordinating care with your existing medical team or our team at WML Wellness to create personalized treatment goals tailored to your mental and physical needs. Illness is systemic and not siloed in the body, so why should healthcare be? Interdisciplinary collaboration means all your healthcare workers discuss your needs for holistic treatment planning, considering all aspects of your health, physical and mental. Your clinicians at Wendie Lubinsky Counseling will work closely with your other healthcare providers to create a personalized treatment plan tailored just for you. With your permission, we may contact them to coordinate treatment, ensure safety, and avoid conflicting recommendations for your care. Your Personalized Wellness includes:

Your care coordinator facilitates conversations among your providers
You have access to a PCP, psychiatric NP, nutritionist/dietician, hormone specialist if needed, and your mental health counselor OR we can coordinate care with your current clinicians
All clinicians discuss your treatment and create aligned goals to help you achieve the wellness results you want

Please take a moment to answer the following questions to discover a personalized WML Wellness plan just for you.

Current Healthcare Providers

Do you currently see any other healthcare providers (not another counselor) outside of Wendie Lubinsky Counseling?(Required)

Yes

Primary Care Provider(Required)

Mental Health Provider

Specialist(s) (e.g., cardiology, neurology, orthopedics)

Alternative/Complementary Providers (e.g., acupuncture, chiropractic, nutrition, physical therapy)

Frequency of Care

How often do you see each provider?(Required)

Care Experience

Do you feel your care between providers is well-coordinated?(Required)

Yes

Sometimes

Have you received conflicting recommendations from different providers?(Required)

Yes

Communication & Coordination

Would you like for your other healthcare providers to discuss your treatment goals and collaborate on your treatment plan?(Required)

Yes

Have your providers communicated with each other about your care in the past?(Required)

Yes, regularly

Sometimes

Rarely / Never

Do you feel your providers share information effectively?(Required)

Yes, regularly

Sometimes

Unsure

Patient Experience

Do you ever feel like your care is fragmented (different providers not on the same page)?(Required)

Yes

Sometimes

Whole Health Collaborative Care Role

Would you like WML Wellness to help coordinate communication between your providers?(Required)

Yes

What’s most important to you about your care being coordinated?(Required)

Convenience (less repeating myself, shared records)

Safety (avoiding conflicting treatments/medications)

Better outcomes (providers working as a team)

Other

Consent

Would you like to sign a release of information (ROI) so we can communicate with your other providers?(Required)

Yes

Consent

I give permission for Whole Health Collaborative Care to contact the above providers for the purpose of coordinating my care. I understand:

This information will be used only to support my treatment and overall health.
My records are protected under the Health Insurance Portability and Accountability Act (HIPAA).
I may revoke this consent in writing at any time. Revocation does not apply to information already shared before the date of revocation.

This consent will remain valid until(Required)

One year from today’s date

Until revoked in writing

Other

Signature

Contact Number

Email Address

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