STEP 1- INTAKE

Choose a path

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Phone Number

Area CodePhone Number

Email

How do you prefer to be contacted?

How did you hear about me?

Emergency Contact Name

First NameLast Name

Relationship with Emergency Contact

Emergency Contact Phone Number

Area CodePhone Number

In Person Training Clients Only: Preferred Hospital

#1 thing standing in your way of being at the fitness level you desire …

Describe your typical day’s activities

What is your activity level?

Weight (optional)

If unknown that's okay

Height

ft

What’s your current fitness routine, if any?

Do you follow a regular work schedule, do you work days, afternoon or nights? Retired?

How would you describe your fitness expertise?

Please list the physical activities that you participate in outside of the gym and outside of work.:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

If you have any injuries, please list them.

Has your doctor given permission for all types of exercise: cardio, resistance, stretching?

Please list any past joint surgeries if any including their dates.

Has a doctor or physical therapist (or other medical professional)recommended you avoid any particular exercises or movements? If so, what?

Are you experiencing any stresses or motivational problems?

Do you suffer from diabetes, asthma, high or low blood pressure, heart or cognitive issues?

if yes please list:

Are you a current cigarette smoker?

Please rate your readiness for change.

What are your goals?

What are your specific goals with your training (if you have specific goals not already mentioned)?

Why? (Intention driving goal/event?)

Any history of eating disorders?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Have you trained with a personal trainer before?

Are you looking for:

At what times during the day would you prefer to train?

If in person, small group or zoom -List your best times, days for sessions / write n/a if not applicable

How many days per week would you like to train together in person, virtually, combo

If we move forward, is it okay to post photos and videos to social media of training and/or progress photos?

Are you okay with Progress Photos (taken personally)?

What are your expectations of me as your Trainer/ Coach ?

1.)CANCELLATION POLICY

No-shows = no refund

Cancellations with less than 24 hours notice = 90% refund

Cancellations with 24+ hours notice = full refund or credit

If you're sick or showing signs of illness, please stay home. I'd rather reschedule than have you push through and risk spreading it to others (or making yourself worse).

I deeply value your consistency. but I also believe in listening to your body and being respectful of the group. Thank you for understanding and helping maintain a healthy, energized space for everyone.

2.) LATE ARRIVALS Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

4.) PAYMENT & SCHEDULING
Payment is required to confirm and hold your session time. Packages must be paid in full to activate and schedule sessions.

5.) PACKAGE RENEWAL
Please purchase your next package when you have 1–2 sessions remaining to avoid any interruption in scheduling.

6.) SERVICE CONFIRMATION
Submitting this intake form does not guarantee services or scheduling. Sessions are confirmed once availability is reviewed and payment is received.

I understand and agree to these policies

Fitness Coaching Disclaimer & Waiver of Liability

I confirm that the information provided in this form is true and accurate to the best of my knowledge. I understand that this is an application to request fitness coaching from Amy Cicoria, LLC and that all programs and materials provided are for general wellness purposes only.

This agreement applies to all coaching services and training programs delivered in-person, virtually, or via self-paced online formats.

I acknowledge and agree that:
This program does not replace medical advice, diagnosis, or treatment.
I will consult with my physician before beginning any exercise program, and will only participate if medically cleared to do so.
I accept that results are not guaranteed and may vary depending on personal circumstances.
I will take full responsibility for modifying or stopping exercises if needed based on how I feel.

I voluntarily assume all risks of participation and agree to hold harmless and release Amy Cicoria, LLC; Amy H. Cicoria DBA; Fusion Fitness Studio Classes and Training DBA; Dansville Dance Academy; and Stacey Corriea from any and all claims, damages, or liabilities arising from participation, including but not limited to injury, loss, or accidents.

I have read and agree to the Coaching Disclaimer & Waiver above. (Use box to check "yes" if you understand and agree, then also sign and date below)

Check “yes” if you understand and agree to the above Coaching Disclaimer and Waiver, then sign and date below.

Signature

Date Signed

Date