Our medical questionnaire is to collect the information required in order for you to have a safe experience with our professional guidance. Please feel free to share any additional information you deem is relevant to disclose. Thank you for your co-operation.
Medical Questionnaire
Confidentiality & Data Protection Statement
Your privacy and the confidentiality of your personal and medical information are of the highest importance. As part of the intake process, I collect personal and health information that you provide voluntarily through this questionnaire, via email, or during consultation. No personal data is collected automatically through this form.
Your information is processed solely for the purpose of assessing your suitability for services, providing psychological support, managing appointments, and fulfilling professional and legal obligations. The legal basis for processing your data is your consent and, where applicable, the provision of healthcare services.
All information is handled in accordance with the General Data Protection Regulation (GDPR / AVG). Records are stored securely, whether in encrypted digital form or in locked physical storage, and access is restricted to the practitioner only.
Your personal data will not be shared with third parties without your explicit consent, except where disclosure is required by law or necessary to protect your vital interests or those of others.
You have the right to request access to your data, to request correction or deletion where appropriate, to withdraw consent, and to lodge a complaint with the Dutch Data Protection Authority (Autoriteit Persoonsgegevens).
By submitting this questionnaire, you acknowledge that you understand and consent to the processing of your personal data as described above.