Client Intake Form Template – Australia

The Client Intake Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. These versions are both modifiable and ready for printing, tailored to suit your requirements seamlessly.

Template – (Open)

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Sample

Client Intake Form Template – Australia

Editable | Printable

(PDF – 1) (PDF – 2)

Complete Template Online

1. Client Information



2. Referrer Details (if applicable)



3. Reason for Consultation

4. Previous Experience

5. Goals and Objectives

6. Financial Situation Overview

7. Preferred Contact Method

8. Availability for Consultation

9. Confidentiality Acknowledgment

10. Client Consent


PDF

WORD

Examples

Client Intake Form Template – Australia (1)
Client Information:
Name: [Client’s Name]
Address: [Client’s Address]
Phone: [Client’s Phone]
Email: [Client’s Email]
Emergency Contact:
Name: [Emergency Contact Name]
Relationship: [Relationship to Client]
Phone: [Emergency Contact Phone]
Client Background:
Age: [Client’s Age]
Occupation: [Client’s Occupation]
How did you hear about us?: [Referral Source]
Health History:
Do you have any pre-existing medical conditions?: [Yes/No]
If yes, please specify: [Details]
Are you currently taking any medications?: [Yes/No]
If yes, please list: [Medication List]
Goals and Expectations:
What are your primary goals for seeking our services?: [Goals]
What are your expectations from our team?: [Expectations]
Consent:
I hereby consent to the collection of my data as detailed above and authorize the professionals to provide services to me.
Signed: [Client’s Signature]
Date: [Date]
Client Intake Form Template – Australia (2)
Client Details:
Full Name: [Client’s Full Name]
Address Line 1: [Address Line 1]
Address Line 2: [Address Line 2]
City: [City]
Postal Code: [Postal Code]
Phone Number: [Client’s Phone Number]
Email Address: [Client’s Email Address]
Referral Information:
Who referred you to our services?: [Referrer Name]
Were you previously a client?: [Yes/No]
If yes, please provide details: [Previous Services]
Medical and Health Information:
Do you have any allergies?: [Yes/No]
If yes, please specify: [Allergy Details]
Please list any surgeries or medical procedures you have undergone: [Surgeries/Procedures]
Current Lifestyle:
Please describe your current physical activity level: [Activity Level]
Do you follow any specific diet?: [Diet Type]
If yes, please describe: [Diet Description]
Expectations of the Service:
What specific services are you interested in?: [Service Interest]
How do you wish to be contacted?: [Preferred Contact Method]
Client Agreement:
I acknowledge that the information provided is accurate and complete to the best of my knowledge
Signed: [Client’s Signature]
Date: [Date]

Printable

PDF – 1 PDF – 2

Client Intake Form Template - Australia