Basic Intake Form

Basic Intake Form Template for Netherlands

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Key Requirements PROMPT example:

"I need a Basic Intake Form for my Amsterdam-based physiotherapy practice, which will be used starting January 2025, that includes medical history collection and must comply with Dutch healthcare privacy regulations while being available in both Dutch and English languages."

Document background

The Basic Intake Form serves as an essential first step in establishing a formal relationship between service providers and their clients in the Netherlands. This document is designed to collect necessary information while ensuring compliance with Dutch privacy laws and GDPR requirements. The form should be used at the commencement of any new client relationship or service provision, capturing essential personal data, contact information, and relevant service-specific details. It includes mandatory privacy statements and explicit consent mechanisms for data processing, making it suitable for various business contexts while maintaining legal compliance. The Basic Intake Form can be customized based on specific service requirements while retaining its core compliance elements.

Suggested Sections

1. Organization Information: Details of the organization collecting the information, including business name, address, and contact details

2. Client Personal Information: Basic personal details including name, date of birth, contact information, and address

3. Contact Preferences: Client's preferred methods of communication and consent for different types of contact

4. Privacy Statement: GDPR-compliant statement explaining how personal data will be collected, processed, stored, and protected

5. Data Processing Consent: Explicit consent section for data processing, including specific purposes for which data will be used

6. Declaration: Statement confirming that all provided information is accurate and complete

7. Signature Section: Space for date, signature, and name of the person completing the form

Optional Sections

1. Emergency Contact Information: Optional section for emergency contact details - relevant for medical or high-risk service contexts

2. Medical Information: Section for relevant medical information - only include if providing health-related services

3. Financial Information: Section for payment details or financial circumstances - include if service involves financial transactions

4. Service-Specific Questions: Customizable section for questions specific to the service being provided

5. Language Preference: Section for preferred language of communication - relevant in multilingual service contexts

6. Special Requirements: Section for any special needs or accommodations - include if providing in-person services

Suggested Schedules

1. Privacy Policy: Detailed privacy policy document explaining data handling practices

2. Terms and Conditions: General terms and conditions of service provision

3. Service Description: Detailed description of services offered and their scope

4. Data Processing Agreement: If applicable, detailed agreement regarding data processing activities

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 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

Professional Services

Legal Services

Financial Services

Education

Consulting

Social Services

Real Estate

Insurance

Retail

Hospitality

Relevant Teams

Reception

Administration

Client Services

Compliance

Operations

Legal

Customer Support

Data Protection

Client Onboarding

Business Development

Relevant Roles

Office Manager

Client Service Representative

Compliance Officer

Data Protection Officer

Administrative Assistant

Customer Service Manager

Operations Manager

Client Onboarding Specialist

Legal Counsel

Practice Manager

Intake Coordinator

Business Development Manager

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