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Clinical & Rehab Pilates Referral Intake Form

Clinical & Rehab Pilates Referral Intake Form

Take a thorough intake for physio-referred or rehabilitation Pilates clients, covering the condition, pain, and treatment.

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Description

The Clinical and Rehab Pilates Referral Intake Form gives instructors a careful, clinical picture of a client working through injury or recovery. Clients describe the injury or condition, whether a physio or doctor referred them, and where the main issue is, so you can plan rehabilitation Pilates that supports recovery rather than risking a setback.

Understanding how long they’ve had it, their typical pain level, which movements are difficult, and any other treatment they’re having helps you coordinate care and progress safely. Contact details, date of birth, and consent complete the intake, so you can work confidently alongside their clinician and guide each client back to strength and movement at a pace their body can handle.

Rehab Pilates rebuilds strength gently and intelligently. Sign up for a free Fun Forms account to customize the fields and embed this intake form on your website.

Form fields

Everything the Clinical & Rehab Pilates Referral Intake Form above collects — 13 fields across 2 pages, so you can see exactly what it captures before you make it your own.

Your Rehab Assessment

What's the injury or condition we're working with?
Long Answer
Have you been referred by a physio or doctor?
Yes/No
Referring clinician's name (if any)
Short Answer
Where's the main issue?
Dropdown
How long have you had it?
Dropdown
Current pain level on a typical day
Scale
What movements or activities are difficult right now?
Long Answer
Are you having any other treatment (physio, osteo)?
Yes/No

Your Details

Your name
Name
Email address
Email
Contact number
Telephone
Date of birth
Date
Consent
Consent

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Template FAQs

Common questions about the Clinical & Rehab Pilates Referral Intake Form — what it captures, when to use it, and how to make it your own.

What is clinical or rehab Pilates?

It’s Pilates adapted for injury recovery and specific conditions, often following a physio referral, focusing on controlled, safe movement. This intake form captures the clinical detail an instructor needs to plan rehabilitation that supports recovery, not risks it.

Who is this intake form for?

It suits instructors working with clients recovering from injury or managing conditions, often referred by a physio or doctor. Clients complete it so the instructor understands their situation fully before starting rehabilitation-focused Pilates sessions.

Why ask about my referring clinician?

Recording your physio or doctor lets the instructor coordinate care and, where appropriate, work in line with your treatment plan. It helps ensure your Pilates sessions complement rather than conflict with the professional guidance you’re already receiving.

Why record my pain level?

Knowing your typical pain level and which movements are difficult helps the instructor set safe starting points and track progress. It ensures sessions stay within comfortable limits and build strength gradually without aggravating your condition.

Do you coordinate with my physio?

Where you provide their details and consent, the instructor can work in a way that supports your wider treatment. Rehab Pilates is most effective as part of coordinated care, so sharing your other treatment helps everyone pull in the same direction.

Is this intake form free to use?

Yes — it’s completely free with a Fun Forms account. You can customize every field, restyle it to match your brand, embed it on your website in seconds, and it needs no coding at all.

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