Wellness Intake Form Generator for the USA

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Key Requirements PROMPT example:

Wellness Intake Form

"I need a Wellness Intake Form for my new holistic healing center in California that includes comprehensive sections on alternative medicine treatments and emphasizes our focus on mental health services, while ensuring full HIPAA compliance and state-specific privacy requirements."

Document background
The Wellness Intake Form is a fundamental document used across the United States healthcare and wellness industry to initiate the provider-client relationship. This document serves multiple purposes: gathering essential personal and medical information, establishing a baseline health status, documenting informed consent, and ensuring compliance with federal and state healthcare privacy regulations. The form typically includes sections for personal information, medical history, emergency contacts, and current health status, while incorporating required legal disclaimers and privacy notices. It's designed to protect both the provider and client while facilitating appropriate care planning.
Suggested Sections

1. Personal Information: Basic contact details, emergency contacts, and demographic information

2. Medical History: Current and past health conditions, medications, and allergies

3. Privacy Notice: HIPAA-compliant privacy policy and information handling practices

4. Consent Statement: Client acknowledgment and authorization for services

Optional Sections

1. Insurance Information: Details about health insurance coverage for providers accepting insurance

2. Lifestyle Assessment: Diet, exercise, sleep, and stress management details for comprehensive wellness programs

3. Goals and Objectives: Client's wellness goals and expected outcomes for ongoing wellness programs

Suggested Schedules

1. Privacy Policy Details: Detailed HIPAA privacy practices and client rights

2. Service Menu: List of available wellness services and associated costs

3. Cancellation Policy: Terms and conditions for appointment cancellations

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

Industries

HIPAA: Health Insurance Portability and Accountability Act - Sets standards for privacy and security of protected health information (PHI), including requirements for patient consent, information disclosure, and data storage/handling

State Healthcare Privacy Laws: State-specific regulations governing healthcare privacy, including additional privacy requirements, medical record retention periods, and specific consent requirements that vary by jurisdiction

ADA: Americans with Disabilities Act - Ensures accessibility in form format, requires non-discriminatory language and practices, and mandates reasonable accommodation considerations

FTC Guidelines: Federal Trade Commission guidelines covering truth in advertising requirements for wellness services and consumer protection regulations

State Healthcare Practice Regulations: State-specific requirements governing healthcare practice, including scope of practice requirements, licensing requirements, and mandatory disclaimers

GINA: Genetic Information Nondiscrimination Act - Provides protection of genetic information and sets limitations on collecting family medical history

Informed Consent Requirements: Legal requirements for obtaining proper informed consent, including clear disclosure of services, risks and benefits, and treatment options

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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