Hello! The attached is what we use at Shriners, as a starting point anyway. Where possible I try to do these in person, in which case it generally evolves into a more in-depth process and other questions occur to me; but most often, it's emailed out to folks who have just stopped coming in (in which case, response rate is never that great, though we do get some!). 

Regards,

Emily Coleman, ecoleman@shrinenet.org