Genesis Integrated Health Strategies

Client Intake & Discovery Form

Thank you for your interest in Genesis Integrated Health Strategies, LLC. This form helps us better understand your organization, current needs, challenges, and desired outcomes so that we can determine how Genesis may best support your goals.

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🔒 Please do not include protected health information (PHI), patient-identifying information, Social Security numbers, financial account information, passwords, or other sensitive personal information on this form.

Organization Information

Organization Name*

Primary Contact*

Title / Position

Email Address*

Phone Number

Website

Organization Address

City / State / ZIP

Organization Type

Select all that apply:

Healthcare OrganizationMedical/Clinical PracticeCorporate/BusinessChurch/Faith-Based OrganizationNonprofit OrganizationCommunity OrganizationGovernment/Public SectorEducational Organization

Other:

How Can Genesis Help?

What prompted you to contact Genesis Integrated Health Strategies?

Areas of Interest

Select all that apply:

Healthcare Operations & Workflow OptimizationPreventive Health & Population Health StrategyCare Coordination / Care IntegrationPatient Experience & EngagementHealthcare Education & Health LiteracyLeadership DevelopmentStaff Training / Professional DevelopmentProcess Improvement / Quality ImprovementOrganizational AssessmentHealthcare Strategy & ConsultingProgram DevelopmentCommunity Health EducationFaith-Based Health & Wellness InitiativesData / Performance Improvement Strategy

Other:

Current State

Briefly describe the primary challenge, opportunity, or concern you would like Genesis to address.

How long has this challenge or opportunity existed?

What approaches have already been attempted?

What appears to be the greatest barrier to improvement?

Current Challenges

Select all that apply:

Workflow inefficienciesCommunication gapsPatient/client engagementStaff engagementTraining or knowledge gapsLeadership/management challengesPreventive health performanceCare coordinationAccess to servicesCustomer service / patient experienceProcess standardizationPerformance measurementHealth literacyResource limitations

Other:

Desired Future State

What would a successful outcome look like for your organization?

What are the top three outcomes you would like to achieve?

Are there specific performance indicators, metrics, or organizational goals associated with this initiative?

YesNoNot Yet Determined

Population & Impact

Who will primarily benefit from this engagement? (Select all that apply)

PatientsEmployees/StaffProviders/Clinical TeamsLeadershipChurch MembersCommunity MembersCustomers/Clients

Other:

Approximate number of individuals impacted

Please describe the population or audience, if applicable:

Engagement Preferences

Preferred Engagement Format

Select all that apply:

On-site consultationVirtual/remote consultationWorkshop or training sessionKeynote or speaking engagementOngoing consulting engagementOne-time project or assessmentHybrid (on-site + virtual)

Other:

Desired Timeline

Immediately (within 30 days)Within 1–3 monthsWithin 3–6 monthsWithin 6–12 monthsExploratory — no set timeline

Estimated Budget Range

Select one:

Under $5,000$5,000 – $10,000$10,000 – $25,000$25,000 – $50,000$50,000+Not yet determined / open to discussion

Decision Maker Information

If different from the primary contact, please provide information for the individual who has authority to approve this engagement.

Name

Title / Position

Phone

Are there additional stakeholders or departments that should be involved in this engagement?

Referral & Discovery

How did you hear about Genesis Integrated Health Strategies?

Referral from colleague or peerLinkedInWebsite / internet searchConference or professional eventSocial mediaEmail or newsletterPrevious engagement with GenesisFaith-based or community network

Other:

Is there anything else you would like us to know before our initial conversation?

Consent & Acknowledgment

By submitting this form, I acknowledge and agree to the following:

•The information provided in this form is accurate and complete to the best of my knowledge.
•I understand that submission of this form does not constitute a formal agreement or contract with Genesis Integrated Health Strategies, LLC.
•Genesis Integrated Health Strategies, LLC will use the information provided solely for the purpose of evaluating how we may best support your organization.
•I consent to being contacted by Genesis Integrated Health Strategies, LLC via the contact information provided above.
•I understand that all information shared will be treated with confidentiality and will not be disclosed to third parties without my consent, except as required by law.
•I have not included any protected health information (PHI), patient-identifying information, or other sensitive personal data in this form.

I have read, understand, and agree to the above acknowledgment. *

Full Name (Electronic Signature) *

Date *

Fields marked * are required. Both you and our team will receive a confirmation upon submission.