Therapy Intake Form Template for Netherlands

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Key Requirements PROMPT example:

Therapy Intake Form

"I need a Therapy Intake Form for my private psychology practice in Amsterdam, compliant with Dutch healthcare laws and GDPR, including online therapy provisions and automated payment processing integration to be implemented by March 2025."

Document background

The Therapy Intake Form is a fundamental document used at the commencement of any therapeutic relationship in the Netherlands. It serves as both a legal and clinical tool, designed to gather comprehensive information about clients while ensuring compliance with Dutch healthcare regulations, including the WGBO, Wet BIG, and GDPR (AVG) requirements. This document is typically used during or before the first therapy session to collect client information, document informed consent, establish the therapeutic framework, and ensure proper data protection protocols. The form includes sections covering personal information, medical history, current concerns, privacy notices, and practice policies. It creates a foundation for the therapeutic relationship while protecting both the client's and practitioner's interests under Dutch law.

Suggested Sections

1. Personal Information: Basic client details including name, date of birth, contact information, emergency contacts, and preferred method of communication

2. Insurance and Payment Information: Details about health insurance, policy numbers, and payment arrangements

3. Medical History: Current and past medical conditions, medications, previous mental health treatment, and family medical history

4. Current Concerns: Primary reasons for seeking therapy, current symptoms, and their duration

5. Privacy Notice: GDPR-compliant explanation of how personal data will be collected, processed, stored, and protected

6. Consent for Treatment: Explicit agreement to receive therapeutic services and acknowledgment of understanding treatment procedures

7. Practice Policies: Information about session duration, cancellation policy, emergency procedures, and communication between sessions

8. Client Rights and Responsibilities: Overview of client's rights under Dutch healthcare laws and their responsibilities in the therapeutic relationship

Optional Sections

1. Substance Use Assessment: Detailed questions about current and past substance use, recommended when substance use issues are indicated

2. Risk Assessment: Questions about self-harm, suicide risk, and violence risk, to be included based on initial screening results

3. Cultural Background: Information about cultural identity and preferences that may impact therapy, recommended for diverse populations

4. Online Therapy Consent: Additional consent and protocols for virtual sessions, required only if offering online therapy

5. Group Participation Agreement: Additional terms for group therapy participation, only needed if offering group sessions

6. Recording Consent: Permission to record sessions for training or supervision purposes, optional based on practice needs

Suggested Schedules

1. Fee Schedule: Detailed breakdown of therapy costs, insurance coverage, and payment terms

2. Privacy Policy: Comprehensive GDPR-compliant privacy policy detailing data handling procedures

3. Crisis Protocol: Detailed procedures for emergency situations and crisis intervention

4. Professional Qualifications: Documentation of therapist's credentials and registrations with relevant Dutch authorities

5. Complaint Procedure: Formal procedure for filing and handling complaints as required by Wkkgz

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Mental Health Services

Medical Services

Psychology

Psychiatry

Social Work

Counseling Services

Healthcare Education

Rehabilitation Services

Relevant Teams

Legal

Compliance

Mental Health Services

Clinical Administration

Quality Assurance

Data Protection

Patient Services

Healthcare Operations

Clinical Records

Risk Management

Relevant Roles

Psychologist

Psychiatrist

Mental Health Therapist

Clinical Social Worker

Counselor

Healthcare Administrator

Practice Manager

Mental Health Nurse

Clinical Director

Intake Coordinator

Healthcare Compliance Officer

Data Protection Officer

Quality Assurance Manager

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