New Client Intake Form

Welcome to Yodgee's Health & Fitness. To help us tailor your upcoming session precisely to your body's physical history and movement goals, please take a few minutes to complete this initial clinical intake form before your appointment. All information provided is held in strict professional confidence.

Practitioner: Joshua Freedman

Credentials: B.Ex.Sport.Sc | B.Hlth.Sc | Dip. Rem. Massage | Dip. Pilates

Accreditation & Associations: ESSA Accredited Exercise Scientist (AES #60480) | AMT Senior Member (#18200)

👤 Section 1: Personal Details

Name *

Date of Birth *

Phone Number *

Email address *

Occupation

Emergency Contact Name & Phone Number *

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💰 Section 2: Funding & Referral Structure

How will your sessions be managed? *

Private (Self-Funded)
Private Health Insurance (Extras)
WorkSafe / WorkCover Victoria Claim
Medicare / EPC (Enhanced Primary Care / Chronic Disease Management) Plan
NDIS Self-Managed
NDIS Plan-Managed
Home Care Package (HCP / Aged Care Provider Managed)
Home Care Package (HCP / Aged Care Self-Managed)

📋 Third-Party, Claim & Package Details

(Only complete this section if your sessions are funded via WorkCover, Medicare/EPC, NDIS, or a Home Care Package. Otherwise, leave blank or write N/A.)

Claim / Participant / HCP/ NDIS ID Number

Funding Provider / Management Agency Name (e.g., WorkSafe Agent, NDIS Plan Manager, or Aged Care Provider)

Case / Care Manager / Support Coordinator Name & Email

Accounts Payable Email for Invoicing

Date of Injury (WorkCover / TAC only)

Treating GP Name & Medical Practice (if applicable)

Please read and check the box below to acknowledge the payment terms for your funding type:

For NDIS Plan-Managed & Provider-Managed HCP Clients: We will issue itemised invoices directly to your nominated Plan Manager, Case Manager, or Provider Accounts department for payment.
For Private, WorkCover & Self-Managed HCP Clients: Payment is required in full on the day of your session. Once paid, we will provide an itemised tax receipt featuring our provider number, which you can submit directly to WorkSafe, your private health insurer, or your HCP self-management portal to claim your reimbursement.

Payment & Invoicing Acknowledgement *

I understand and agree to the payment and invoicing terms for my selected funding type.

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🩺 Section 3: Health & Medical History

What specific outcomes are you hoping to achieve through our sessions?

Relevant Health Conditions or Diagnoses

Chronic Pain / Joint Stiffness
Hypermobility / Joint Instability
Anxiety / Stress Management
Past Musculoskeletal Injuries or Surgeries
Other (please specify below)

If you selected "Other," please provide details

Are you currently taking any regular medications that may affect your blood pressure, balance, or physical performance? *

Do you have any known allergies or skin sensitivities we should be aware of? (e.g. massage oils, latex, adhesive tape, particular fabrics) *

Current Medical Considerations: Please detail any conditions we should factor into your program. *

Please list any current or past physical injuries, surgeries, or joint restrictions (including approximate dates)

If you ticked any areas, please provide more details (e.g., "lower back stiffness when sitting")

Are you currently pregnant? *

Yes
No
N/A

If yes — approximate due date (leave blank if not applicable)

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💬 Section 4: Environment & Communication Preferences

Communication & Environment Support. Please let us know of any specific communication styles (verbal/non-verbal), sensory triggers, or support preferences we should accommodate.

🏃 Section 5: Exercise & Lifestyle History

Please describe your current exercise routine (type of exercise, frequency, and intensity) *

Have you ever trained or competed at an elite level in any sport or movement discipline? *

Yes
No

if yes, please specify

How did you hear about Yodgee's Health & Fitness?

May we use photos or videos from your sessions for promotional purposes (e.g. website, social media, testimonials)? This choice has no effect on your ability to book sessions.

Photo/Video Consent *

Yes
No

Liability & Cancellation Declaration

• I agree that the information I have given on this document is true and correct. I take full responsibility for my actions at all times on the premises where the sessions conducted by Yodgee's Health & Fitness take place.

• I am aware that at times hands-on or tactile pressure may be needed together posing an element of risk or injury whilst undertaking any activities during my sessions. This includes any incident or event during any workouts or classes and use of equipment whilst engaged in activities on the premises where sessions conducted by Yodgee's Health & Fitness take place.

Cancellation Policy

For Private & WorkSafe Clients: I understand that I must give 24 hours' notice of booking cancellation or the full session fee will be charged.
For NDIS Clients: Cancellations are managed strictly in accordance with the terms agreed upon in my signed Yodgee's Health & Fitness Service Agreement and current NDIS guidelines.
For Home Care Package (HCP) Clients: Cancellations are managed in accordance with the terms agreed upon in your Home Care Package service agreement. Self-Managed HCP clients follow the same 24-hour notice period as Private clients; Provider-Managed HCP clients should refer to their Aged Care Provider's cancellation terms.

Read our full Privacy Policy to learn how we protect your personal health information

Liability & Cancellation Acknowledgment *

I have read, understood, and agree to the liability waiver and 24-hour cancellation policy.

Full Name (as signature) *

Date *

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