By filling out the Treatment Contract form, I hereby give my consent to the processing of my health data in connection with my treatment in the practice of Susanne Stauch, alternative practitioner for psychotherapy, who is responsible under data protection law.
I hereby confirm the following:
- I have been informed that the processing of my data is necessary for the purpose of medical treatment (anamnesis, assessment of findings, diagnosis, therapy, aftercare, etc.) as well as due to the underlying treatment contract.
- I have been informed that the consent includes the processing of sensitive health data.
- I have been provided with the information required for proper information by the responsible person prior to data collection.
- My consent is voluntary. I am aware that I am not obliged to give this consent.
If I do not give this consent, I will not suffer any disadvantages as a result. Without consent, however, no treatment can be carried out by the person responsible.
- I have taken note of the contents of the revocation instruction before giving my consent.
This consent can be revoked at any time and without giving reasons. This does not affect the lawfulness of the processing carried out on the basis of the consent until revocation. Legal permissions remain unaffected by a revocation of consent. In the event of revocation, a continuation of the treatment by the person responsible is basically no longer possible. Consent may be revoked verbally or in writing. The revocation is to be addressed to: Susanne Stauch.