Therapy Intake Form Template for Indonesia

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Key Requirements PROMPT example:

Therapy Intake Form

"I need a Therapy Intake Form for my private psychology practice in Jakarta, Indonesia, that includes telehealth services and caters to adult clients only, with special attention to data privacy and online session protocols."

Document background

The Therapy Intake Form is a fundamental document used at the commencement of mental health services in Indonesia. It serves multiple purposes: collecting comprehensive client information, documenting informed consent, and establishing the therapeutic relationship within the framework of Indonesian healthcare laws. This document is essential for compliance with Law No. 36 of 2009 on Health and Law No. 18 of 2014 on Mental Health, which govern healthcare services and mental health practice in Indonesia. The form includes sections for personal information, medical history, current symptoms, risk assessment, and various consents, ensuring thorough documentation and legal compliance while facilitating appropriate mental health care delivery.

Suggested Sections

1. Personal Information: Basic client details including name, date of birth, address, contact information, and emergency contact details

2. Medical History: Current and past medical conditions, medications, allergies, and previous hospitalizations

3. Mental Health History: Previous mental health treatment, diagnoses, and medications

4. Current Symptoms and Concerns: Present mental health challenges, symptoms, and reasons for seeking therapy

5. Risk Assessment: Evaluation of current suicide risk, self-harm history, and violence risk factors

6. Privacy Notice: Information about how personal data is collected, stored, and protected in accordance with Indonesian law

7. Informed Consent: Details about therapy services, risks, benefits, and client rights under Indonesian healthcare laws

8. Payment and Cancellation Policy: Fee structure, payment terms, and cancellation/missed session policies

9. Emergency Procedures: Protocol for crisis situations and emergency contact procedures

Optional Sections

1. Insurance Information: Details about health insurance coverage, if applicable - used when the practice accepts insurance

2. Telehealth Consent: Additional consent for online therapy services - required when offering virtual sessions

3. Cultural/Religious Considerations: Specific cultural or religious factors that may impact treatment - used in practices serving diverse populations

4. Release of Information: Authorization to share information with other healthcare providers - used when coordination of care is needed

5. Substance Use History: Detailed substance use assessment - included for practices dealing with addiction or substance use issues

Suggested Schedules

1. Schedule A - Fee Schedule: Detailed breakdown of service fees and payment options

2. Schedule B - Privacy Policy: Detailed privacy policy in compliance with Indonesian data protection laws

3. Schedule C - Client Rights and Responsibilities: Comprehensive list of client rights and responsibilities under Indonesian healthcare laws

4. Appendix 1 - Crisis Resources: List of emergency contacts and crisis resources

5. Appendix 2 - Symptom Checklist: Standardized mental health symptom assessment form

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

Mental Health Services

Medical Services

Counseling Services

Psychology Services

Social Services

Healthcare Education

Wellness and Wellbeing

Relevant Teams

Mental Health Services

Clinical Operations

Healthcare Administration

Legal and Compliance

Quality Assurance

Client Services

Medical Records

Risk Management

Relevant Roles

Mental Health Therapist

Clinical Psychologist

Psychiatrist

Counselor

Mental Health Nurse

Healthcare Administrator

Medical Records Officer

Practice Manager

Healthcare Compliance Officer

Mental Health Service Coordinator

Client Services Manager

Quality Assurance Manager

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Authors

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