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Intake Assessment Form

Intake Assessment Form Template for Indonesia

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Key Requirements PROMPT example:

Intake Assessment Form

"I need an Intake Assessment Form for my Jakarta-based mental health clinic, compliant with Indonesian healthcare regulations, that includes comprehensive mental health screening sections and accommodates cultural sensitivities in both Bahasa Indonesia and English."

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Document background
The Intake Assessment Form serves as a crucial first step in documenting client/patient information and assessment in Indonesian healthcare and social service settings. This document is specifically designed to comply with Indonesian regulations, including Law No. 36 of 2009 on Health, the PDP Law, and relevant ministerial regulations on medical records. The form is typically used during initial contact with new clients/patients to collect comprehensive information about their personal details, medical history, current conditions, and service needs. It includes mandatory privacy notices and consent sections as required by Indonesian law, and can be customized for various service contexts while maintaining regulatory compliance. The Intake Assessment Form supports proper documentation, informed decision-making, and appropriate service planning while protecting both the service provider and client/patient interests.
Suggested Sections

1. Personal Information: Basic demographic data including name, date of birth, ID number, contact details, and address

2. Emergency Contact Information: Details of primary and secondary emergency contacts

3. Medical History: Current and past medical conditions, medications, allergies, and previous treatments

4. Current Symptoms/Concerns: Present health issues or concerns that led to seeking services

5. Lifestyle Assessment: Daily activities, living situation, occupation, and lifestyle factors

6. Insurance Information: Health insurance details, coverage type, and policy numbers

7. Consent and Privacy Notice: Information about data collection, usage, and storage as per PDP Law requirements

8. Authorization: Client/guardian signatures and date, witness signatures if required

Optional Sections

1. Mental Health Assessment: For mental health services - includes psychological history and current mental state evaluation

2. Social Support Assessment: For social service intake - details about family structure, support systems, and community resources

3. Nutritional Assessment: For nutrition-related services - dietary habits, restrictions, and nutritional concerns

4. Functional Assessment: For rehabilitation services - evaluation of physical capabilities and limitations

5. Financial Assessment: For social welfare services - income information and financial assistance needs

6. Cultural/Religious Considerations: When relevant to service provision - specific cultural or religious needs and preferences

Suggested Schedules

1. Medical History Form: Detailed template for recording comprehensive medical history

2. Medication List: Current and past medication details including dosage and frequency

3. Risk Assessment Checklist: Standardized checklist for identifying potential health or safety risks

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

5. Service Consent Forms: Specific consent forms for different types of services or treatments

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 legal definitions
Personal Data
Sensitive Health Information
Healthcare Provider
Medical History
Emergency Contact
Legal Guardian
Consent
Treatment
Assessment
Service Plan
Medical Records
Healthcare Facility
Insurance Provider
Primary Care Provider
Referral
Confidentiality
Data Processing
Data Controller
Previous Treatment
Current Medication
Allergies
Pre-existing Conditions
Privacy Notice
Authorization
Electronic Health Record
Data Protection Officer
Medical Emergency
Healthcare Services
Insurance Coverage
Treatment Plan
Relevant Industries

Healthcare

Mental Health Services

Social Services

Elder Care

Rehabilitation Services

Public Health

Medical Research

Insurance

Community Services

Disability Services

Relevant Teams

Administration

Clinical Operations

Patient Services

Medical Records

Quality Assurance

Compliance

Front Desk

Care Coordination

Risk Management

Data Management

Relevant Roles

Healthcare Administrator

Medical Doctor

Nurse

Social Worker

Mental Health Professional

Case Manager

Intake Coordinator

Clinical Director

Patient Services Manager

Healthcare Compliance Officer

Medical Records Manager

Registration Specialist

Administrative Assistant

Quality Assurance Manager

Industries
Law No. 36 of 2009 on Health: Indonesia's primary health law that governs healthcare services, patient rights, and medical documentation requirements
Law No. 27 of 2022 on Personal Data Protection (PDP Law): Regulates the collection, processing, and storage of personal data, including sensitive health information in forms
Minister of Health Regulation No. 269/MENKES/PER/III/2008: Specific regulations on medical records and documentation requirements in healthcare settings
Law No. 11 of 2008 on Electronic Information and Transactions: Relevant if the intake form is processed or stored electronically
Law No. 8 of 1999 on Consumer Protection: Ensures protection of consumer rights when providing personal information in healthcare or service settings
Law No. 11 of 2009 on Social Welfare: Relevant if the intake assessment is related to social services or welfare programs
Government Regulation No. 47 of 2016 on Health Service Facilities: Provides standards for health facility operations including documentation 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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