Client Intake

This Client Intake form is the first step of the program you have opted for. The information you provide will be used to develop your program.

If you have any questions please let me know via:

email
phone or text Gemma on 0419 562 800
message through the socials

Our whole business is built around 1:1 relationships and working with you to develop programs that suit YOUR needs and and fit in with YOUR life situation.

We know that there can be a big difference between businesses saying they do something and then actually doing it, so why not have a look at what some of our clients are saying about Regular Jane’s Fitness and Nutrition.

Client Intake Form - Start Me Up / Keep Me Going / Workin' It

A Bit About You

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone (optional)

Your suburb(Required)

Tell me a bit about you - work, study, retired, hobbies, interests, etc(Required)

Have you done online coaching/workouts before?(Required)

Which Program would you like to choose?(Required)

Get Me Started: 1x6 week personalised exercise program ($100)

Keep Me Going: ongoing 6 weekly personalised exercise subscription program ($140 every 6 weeks)

Workin' It: ongoing personalised exercise and coaching subscription program ($180 per month)

When would you like to start?(Required)

MM slash DD slash YYYY

Program Details

This information will help me to design your program

Describe your current physical activity/exercise levels in a typical week(Required)

What physical activity/exercise are you doing now? How often per week, how intense is it, etc. This will help me understand your fitness level and what you're used to doing.

If you've chosen for the home, do you have any equipment?(Required)

Please be descriptive, i.e., what kg of hand weights, what type of resistance bands, and what brand/style of home gym system. The more detail you provide, the better I can program for you.

Have you tried in the past to get fit/healthier? If so, how?(Required)

What exercises/movement do you enjoy most?(Required)

What exercises/movement do you dislike or even hate?(Required)

Are there any exercises you’ve wanted to try?(Required)

How would you rate your current health and wellbeing?(Required)

What’s your initial goal – what do you want from the program?(Required)

i.e., learn to use weights at the gym, lose weight, gain muscle/strength, run/walk x km, and regularly exercise as part of a weekly routine.

Are there any obstacles or barriers that could block your progress?(Required)

i.e. holidays, time/schedule, motivation, etc.

Realistically, how many sessions would you like your program to cover and maximum duration?(Required)

What days will work best for you to workout?(Required)

i.e., 3 days per week, 20 minutes a session. If you have chosen both gym and home, please specify for each, i.e., 2 gyms, 1 home.

Pre-exercise Questionnaire

This information is important for me understand you and your current health status better

Age(Required)

Please enter a number from 0 to 100.

Do you have any medical conditions/medications/restrictions that may require special consideration for you to exercise?(Required)

This includes long-term, current or recent injuries, surgery, chronic conditions, pregnancy and childbirth within the past 12 months.

Yes

If you answered yes to the above, please share relevant information below

Medical guidance is recommended:

If you answered YES to any of the above questions, you are advised to seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

Consent(Required)

I believe that to the best of my knowledge, all of the information I have supplied within this Client Intake Form is correct

Signature(Required)

This field is hidden when viewing the form

Date signed

MM slash DD slash YYYY

Important Information

We collect the above information about your health and medical history so that we have as much relevant informaiton as possible to provide you with a suitable and safe exercise program.

By signing:(Required)

I certify that I have answered all the above questions correctly and to the best of my knowledge, free from any medical conditions which may be aggrevated by physical exertion.

I agree to hold harmless the establishment, all management, including volunteers, from and against any and all claims. I agree to update my coach regarding changes in my health and understand that there shall be no liabilty on the trainer's part should I not do so

I am aware of possible side effects and risks associated with physical exercise.

I agree to inform the trainer if I experience pain or discomfort during a session.

Cancellations(Required)

Start Me Up: I agree to the training commitment of 6 weeks, paid in full and upfront.

Keep Me Going & Workin' It: I agree to the minimum training commitment of 1 month Workin' It/6 weeks Keep me Going. After the initial training commitment, my subscription will automatically continue from the nominated bank account via Stripe. Two weeks notice in writing is required to cancel.

I understand that refunds may be provided within ACCC Guidelines.

I agree to maintain product integrity and not distribute any Regular Jane's Fitness & Nutrition or Gemma Merrick materials without express permission.

Which program would you like to choose?(Required)

Get Me Started: 1x6 week personalised exercise program ($100)

Keep Me Going: Ongoing 6 weekly personalised exercise subscription program ($140 every 6 weeks)

Workin' It: Oongoing personalised exercise and coaching subscription program ($180 p.m)

Total

Credit Card(Required)

Client Intake

Client Intake Form - Start Me Up / Keep Me Going / Workin' It

A Bit About You

Program Details

Pre-exercise Questionnaire

Medical guidance is recommended:

Important Information

Contact Details

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