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Health Coach Intake Form

Health Coach Intake Form Template for Indonesia

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Key Requirements PROMPT example:

Health Coach Intake Form

"I need a Health Coach Intake Form for my corporate wellness program launching in Jakarta in March 2025, which should be available in both English and Bahasa Indonesia, with specific sections for employee wellness goals and stress management."

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Document background
The Health Coach Intake Form is a crucial document used at the initiation of a health coaching relationship in Indonesia. It serves multiple purposes: collecting comprehensive client information, establishing the scope of services, and ensuring compliance with Indonesian healthcare and data protection regulations. The form should be completed before the commencement of health coaching services and includes sections covering personal information, health history, lifestyle assessment, and client goals. It incorporates necessary legal elements such as privacy notices, terms of service, and disclaimers to protect both the coach and client. This document is particularly important in the Indonesian context where health service providers must adhere to specific regulations regarding patient information collection and data protection under Law No. 36 of 2009 on Health and the PDP Law of 2022.
Suggested Sections

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

2. Health History: Current health conditions, medications, allergies, and past medical procedures

3. Lifestyle Assessment: Current diet, exercise habits, sleep patterns, and stress levels

4. Goals and Expectations: Client's specific health and wellness goals, timeframes, and desired outcomes

5. Privacy Notice and Data Consent: Information about how personal data will be collected, stored, and used in compliance with Indonesian PDP Law

6. Terms and Conditions: General terms of service, cancellation policies, and scope of health coaching services

7. Disclaimer: Statement clarifying that health coaching is not medical advice and does not replace medical treatment

8. Client Acknowledgment: Client's confirmation of accurate information provision and understanding of terms

Optional Sections

1. Medical Provider Information: Section for listing current healthcare providers and their contact details - used when client is under medical care

2. Dietary Restrictions: Detailed section about food allergies, religious or cultural dietary restrictions - used when nutrition coaching is involved

3. Physical Activity Readiness: Questions about physical limitations and exercise restrictions - used when exercise coaching is part of the service

4. Mental Health History: Information about mental health conditions and treatments - used when stress management or behavioral coaching is included

5. Pregnancy/Postpartum Information: Specific questions for pregnant or postpartum clients - used when working with this specific population

Suggested Schedules

1. Health History Questionnaire: Detailed questionnaire about past and current health conditions

2. Lifestyle Questionnaire: In-depth assessment of daily habits, routines, and lifestyle factors

3. Food and Activity Journal Template: Template for tracking daily meals and physical activity

4. Privacy Policy: Detailed privacy policy compliant with Indonesian PDP Law

5. Coaching Service Terms: Comprehensive terms of service including scope, limitations, and client responsibilities

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

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Wellness and Fitness

Personal Services

Alternative Medicine

Preventive Healthcare

Corporate Wellness

Health Education

Sports and Recreation

Relevant Teams

Legal

Compliance

Healthcare Services

Client Relations

Operations

Administrative Support

Risk Management

Data Protection

Quality Assurance

Wellness Services

Relevant Roles

Health Coach

Wellness Coach

Fitness Trainer

Nutrition Coach

Lifestyle Coach

Corporate Wellness Coordinator

Wellness Program Manager

Healthcare Administrator

Compliance Officer

Privacy Officer

Legal Counsel

Client Relations Manager

Practice Manager

Industries
Law No. 36 of 2009 on Health: Indonesia's primary health law that governs healthcare services, including provisions for healthcare providers and patient rights
Law No. 29 of 2004 on Medical Practice: Regulates medical practice and healthcare service providers, including requirements for providing health-related services
Law No. 27 of 2022 on Personal Data Protection (PDP Law): Indonesia's comprehensive data protection law that governs the collection, processing, and storage of personal data, including sensitive health information
Law No. 8 of 1999 on Consumer Protection: Provides framework for consumer rights and business obligations in service provision, including healthcare services
Indonesian Civil Code (KUHPerdata): Governs contract formation and validity, including service agreements between professionals and clients
Minister of Health Regulation No. 269/MENKES/PER/III/2008: Regulates medical records and documentation requirements for healthcare services
Government Regulation No. 47 of 2016 on Health Service Facilities: Defines various types of health service facilities and their operational requirements
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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