Private Intake Form

Gender

Male Female Non-binary Prefer not to say

Language Spoken at Home

Interpreter Required

Yes No

Preferred Method of Communication

Phone Email Post

Do you identify as Aboriginal and/or Torres Strait Islander?

Yes No

Postal Address (if different from above)

Relationship to Client

What do you want to achieve for yourself – life skills, physically, socially, etc?

I understand that:

YouGo Physio owns these records and will be kept confidential.
Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties.
I can ask to see records and receive a copy.
Records are archived for a set period according to policy and procedure.

To the best of my knowledge, the information provided in this form is true and correct.