Case Management Intake Form for Canada

Case Management Intake Form Template for Canada

A comprehensive intake documentation tool used across Canadian social service and healthcare organizations to initiate case management services. This form complies with federal and provincial privacy legislation, including PIPEDA and provincial health information protection acts. It captures essential client information, service needs, risk factors, and consent requirements while establishing the foundation for service delivery planning. The document incorporates necessary elements for various service contexts while maintaining compliance with Canadian regulatory requirements for information collection and privacy protection.

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What is a Case Management Intake Form?

The Case Management Intake Form serves as the primary documentation tool for initiating professional support services across Canadian social service and healthcare organizations. This document is essential when beginning a new client relationship, gathering comprehensive information needed for service planning while ensuring compliance with Canadian privacy legislation. It is designed to capture critical client data, including personal information, presenting issues, medical history, and consent for services, while maintaining appropriate privacy safeguards. The form supports various service contexts, from mental health to elder care, and helps establish the foundation for ongoing case management relationships. It includes both mandatory sections required for all clients and optional components that can be utilized based on specific service needs or circumstances.

What sections should be included in a Case Management Intake Form?

1. Client Information: Basic personal information including name, date of birth, contact details, and identification numbers

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

3. Presenting Issues: Description of current challenges, concerns, and reasons for seeking services

4. Medical Information: Current health status, medications, allergies, and relevant medical history

5. Current Living Situation: Housing status, household composition, and living arrangements

6. Income and Employment: Employment status, income sources, and financial situation

7. Consent and Privacy: Client consent for services and information sharing, privacy policy acknowledgment

8. Risk Assessment: Initial screening for immediate risks or safety concerns

What sections are optional to include in a Case Management Intake Form?

1. Cultural Background: Information about cultural identity, language preferences, and religious/spiritual beliefs - used when providing culturally sensitive services

2. Legal Status: Information about legal issues, custody arrangements, or court orders - used when legal matters are relevant to case management

3. Education History: Educational background and current educational status - used when education-related goals are part of case management

4. Substance Use History: Information about current or past substance use - used when addiction services may be needed

5. Previous Service History: History of involvement with other service providers or agencies - used when coordination with other services is needed

6. Military Service: Details of military service and veteran status - used when working with veterans

What schedules should be included in a Case Management Intake Form?

1. Consent Forms: Collection of required consent forms including information sharing, release of information, and service consent

2. Rights and Responsibilities: Document outlining client rights, responsibilities, and agency policies

3. Service Agreement: Details of services to be provided, expectations, and conditions

4. Resource List: List of community resources and referral information relevant to client needs

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

Cost

Free to use

Relevant legal definitions

Clauses

Personal Information Collection
Consent and Authorization
Privacy and Confidentiality
Information Sharing
Emergency Procedures
Rights and Responsibilities
Service Description
Risk Assessment
Medical Information
Financial Information
Documentation Requirements
Grievance Procedures
Safety Planning
Release of Information
Service Termination
Record Keeping
Cultural Considerations
Accessibility Accommodations

Relevant Industries

Healthcare

Social Services

Mental Health

Addiction Services

Youth Services

Elder Care

Disability Services

Homeless Services

Family Services

Refugee Services

Relevant Teams

Intake

Case Management

Social Services

Clinical Services

Program Administration

Quality Assurance

Client Services

Operations

Community Outreach

Relevant Roles

Case Manager

Social Worker

Intake Coordinator

Program Director

Clinical Supervisor

Mental Health Worker

Addiction Counselor

Family Support Worker

Healthcare Navigator

Client Services Coordinator

Program Manager

Outreach Worker

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What is a Case Management Intake Form?

What sections should be included in a Case Management Intake Form?

What sections are optional to include in a Case Management Intake Form?

What schedules should be included in a Case Management Intake Form?

Authors

Alex Denne

Jurisdiction

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Document Type

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