Client Intake Form Generator for the USA

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Key Requirements PROMPT example:

Client Intake Form

"I need a Client Intake Form for my new medical practice in California, compliant with HIPAA and state regulations, that captures both general patient information and detailed medical history for appointments starting January 2025."

Document background

The Client Intake Form is a crucial document used across various professional sectors in the United States to systematically gather client information at the commencement of services. This document typically includes personal identification details, service requirements, relevant history, and specific information pertinent to the service being provided. It must comply with federal regulations such as HIPAA and GLBA, as well as state-specific privacy laws. The form serves multiple purposes: establishing the client relationship, ensuring regulatory compliance, identifying client needs, and creating a foundation for service delivery. It's particularly important for maintaining accurate records and ensuring appropriate service delivery while protecting both the service provider and client.

Suggested Sections

1. Client Information: Basic contact details including name, address, phone, email, and preferred contact method

2. Service Requirements: Nature of services needed or reason for engagement, including specific requirements or preferences

3. Privacy Notice: Statement on how client information will be used and protected, including data handling practices

4. Consent Statement: Client authorization to collect and process information, including specific permissions and acknowledgments

Optional Sections

1. Medical History: Detailed medical background including conditions, medications, and treatment history - for healthcare services

2. Financial Information: Income details, assets, financial obligations, and credit information - for financial or legal services

3. Emergency Contacts: Alternative contact information and relationship details - for healthcare or personal care services

4. Insurance Information: Details of relevant insurance policies and coverage - for healthcare or professional services

5. Professional References: References from other service providers or professionals - for business or professional services

Suggested Schedules

1. Privacy Policy: Detailed privacy policy document explaining how client information is collected, used, stored, and protected

2. Service Terms: Comprehensive terms of service including rights, responsibilities, and limitations

3. Required Disclosures: State or industry-specific required disclosures and compliance statements

4. Fee Schedule: Detailed breakdown of service fees, payment terms, and billing procedures

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
Legal Services
Financial Services
Professional Services
Social Services

Relevant Teams

Client Services
Operations
Compliance
Legal
Administration

Relevant Roles

Office Manager
Compliance Officer
Client Services Manager
Practice Administrator
Intake Coordinator

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Electronic Intake Forms

Legal framework for electronic intake forms compliant with US federal and state regulations, governing digital information collection and processing.

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Authors

Alex Denne

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