• Complete Your Resilient Movement Intake

    Please complete this short intake before your first session. It usually takes about 5–7 minutes. You'll only see questions that apply to you.

  • Welcome / Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Training Days*
  • Preferred Training Times*
  • What are your main goals?*

  • Jeff may require medical clearance before structured exercise begins. Jeff will review your intake and let you know exactly what is needed.

  • Pre-Exercise Health Screening

  • Notice
  • Has a healthcare provider told you to limit exercise or exercise only with supervision?*
  • Do you currently have chest pain, unexplained shortness of breath, fainting, or severe dizziness?*
  • Do you have a bone, joint, muscle, or pain issue that may affect exercise?*
  • Have you had surgery, hospitalization, or a significant procedure within the past 12 months?*
  • Do you have a chronic medical condition or take medication that could affect exercise response?*
  • Is there any other reason you think exercise should be delayed, modified, or medically reviewed before starting?*

  • Health History

  • Please check anything that applies:

  • Current Activity / Function / Recovery

  • Any exercise-related symptoms, limitations, or movements you already know bother you?

  • Adaptive Addendum

  • Mobility device used, if any
  • Do you need assistance with transfers?
  • Any sensory, communication, or processing considerations?
  • Will a caregiver or support person join your sessions?
  • Best coaching style or communication preference

  • Senior Strength / Balance - Additional Questions

    Please answer these additional questions so we can better support your training.
  • Have you had any falls in the past 12 months?*
  • Do you have concerns about your balance?
  • Do you use a cane, walker, or other mobility device?*
  • Do you have difficulty with stairs or getting up from a chair or the floor?*

  • Post-PT / Post-Surgery Addendum

  • This section is for post-PT or post-surgery clients only.
  • Are you discharged from PT / cleared to return to exercise?
  • PT discharge date (if known)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Informed Consent / Scope

  • Informed Consent, Waiver, and Service Agreement

    Read this before you sign. Signing means you agree to all of it.

    1. Exercise carries risk. Physical training can cause injury. That includes muscle strains, sprains, falls, broken bones, and in rare cases heart attack, stroke, or death. I understand these risks and I choose to train anyway.

    2. I will report changes. I am responsible for telling my trainer about any change in my health, medications, injuries, or symptoms, before or during a session. If something changes between sessions, I will say so.

    3. I can stop at any time. I may slow down, modify, or stop any exercise for any reason. I do not need permission and I will not be pressured to keep going.

    4. This is fitness coaching, not medical care. Resilient Movement provides fitness coaching and exercise instruction. It is not medical treatment, physical therapy, or a replacement for advice from my doctor. Nothing here diagnoses or treats a medical condition.

    5. My trainer may change or end a session. For safety, the trainer may modify an exercise, lower the intensity, or end a session early.

    6. 24 hour cancellation. I will give at least 24 hours notice to cancel or reschedule. Less than 24 hours notice, or not showing up, counts as a used session.

    7. Late arrival. If I arrive late, the session still ends at its scheduled time. Being late does not extend the session.

    8. Payment and packages. Sessions and packages are paid according to the rates and terms provided at the time of purchase.

    9. No guaranteed results. Fitness results depend on many things, including effort, consistency, sleep, nutrition, and genetics. No specific result is promised or guaranteed.

    10. Emergency care. If I appear to need emergency help, I authorize my trainer to call 911 and to provide first aid, CPR, or use an AED. I am responsible for any costs of emergency treatment or transport.

    11. Release of liability. I release Resilient Movement LLC, Jeff Williamson, and any facility where training takes place from claims for injury, loss, or damage connected to my participation, except where caused by gross negligence or willful misconduct.

    12. Age. I am 18 or older. If the client is under 18, I am the parent or legal guardian signing on their behalf.

    By checking the box and signing below, I confirm that I have read this agreement, I understand it, and I agree to it.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Media Authorization

  • Photo/video preference (optional
  •  
  • Should be Empty: