Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail.

The Wellness Assessments here can be printed blank or, with the editable form, you can type in the information for the top section before printing the form.

Adult Wellness Assessment (English): blank or editable

Youth Wellness Assessment (English): blank or editable

Adult Wellness Assessment (Spanish): blank or editable

Youth Wellness Assessment (Spanish): blank or editable

WA Instruction Page:  English or Spanish

Sample completed WA: English or Spanish

WA Client Education Sheet

Wellness Assessments are also available at the secure transaction section of Provider Express for registered users!

Log in and click on the ALERT tab. Here you can print out Wellness Assessments that can be pre-populated with the name of the clinician* and member name.
*Note: A clinician number will be pre-populated on the form. For the confidentiality of those clinicians whose Tax ID is their social security number, all clinician numbers presented on these WA forms are Optum-assigned numbers.

Notes about the Wellness Assessment forms:

  • It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us.
  • There is only one Wellness Assessment form; it is the same one that is offered to members at the first and second time.