Intake Form - Praktijk Vrije Geest

Therapy Preferences

Preferred Session Frequency *

Weekly

Every 2 weeks

Monthly

Preferred Days *

Select all days that work for you

Preferred Time(s) of Day *

Select all time periods that work for you

Therapy Format Preference *

In-person

Online (video call)

Either / No preference

Required Consents

Please read and agree to the following to proceed with your intake.

Data Processing Consent *

I consent to the processing of my personal data for the purpose of therapy services as described in the Privacy Policy.

Medical Data Consent (GDPR Article 9) *

I consent to the processing of my health and medical data, which is considered sensitive data under GDPR Article 9. This data is necessary for providing appropriate therapy services.

Communication Consent *

I consent to receiving appointment reminders and important communications via email and/or SMS regarding my therapy sessions.

Data Retention Acknowledgment *

I understand that my medical records will be retained for 30 years as required by Belgian healthcare law. I can request anonymization of my data after my treatment ends, but the anonymized records will be retained for the legal retention period.

Preferences & Consent

Therapy Preferences

Required Consents