Counseling Intake Form Template for Canada

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Counseling Intake Form

I need a Counseling Intake Form for my private practice specializing in adolescent mental health and family therapy, with specific sections for parental consent and social media policies, compliant with Canadian privacy laws.

Document background

The Counseling Intake Form is a foundational document used at the commencement of therapeutic services in Canadian mental health practices. This document serves multiple crucial purposes: it collects essential client information, establishes the therapeutic relationship, ensures compliance with privacy legislation, and documents informed consent. The form must adhere to federal privacy laws (PIPEDA) and provincial health information privacy acts, while meeting professional standards set by regulatory bodies. It is typically completed before or during the first counseling session and includes sections for personal information, medical history, current concerns, risk assessment, and various consents. The document is designed to protect both the client's rights and the practitioner's professional obligations while facilitating the initial phase of the therapeutic relationship.

Suggested Sections

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

2. Insurance and Payment Information: Details about insurance coverage, policy numbers, and preferred payment methods

3. Current Concerns: Primary reasons for seeking counseling, current symptoms, and duration of concerns

4. Medical History: Relevant medical conditions, medications, previous mental health treatment, and family medical history

5. Risk Assessment: Questions about self-harm, suicide risk, and harm to others

6. Current Support System: Information about family, friends, other healthcare providers, and existing support networks

7. Privacy Policy Acknowledgment: Statement of understanding regarding confidentiality and its limits

8. Informed Consent: Consent for treatment, including risks, benefits, and client rights

9. Fee Agreement: Acknowledgment of fee structure, cancellation policy, and payment terms

Optional Sections

1. Substance Use History: Details about current and past substance use - include for addiction counseling services

2. Trauma History: Information about past traumatic experiences - include for trauma-focused therapy

3. Cultural Background: Information about cultural identity and preferences - include for culturally-sensitive counseling

4. Educational/Employment History: Details about academic and work history - include for career counseling or when relevant to treatment

5. Relationship Status: Detailed information about current and past relationships - include for relationship counseling

6. Parent/Guardian Information: Additional details for minors or dependent adults - include when client is not legally independent

7. Military Service History: Details about military service - include for veteran clients

8. Religious/Spiritual Background: Information about religious or spiritual beliefs - include when relevant to treatment approach

Suggested Schedules

1. Schedule A - Privacy Policy: Detailed privacy policy explaining how personal information is collected, used, and protected

2. Schedule B - Client Rights and Responsibilities: Comprehensive list of client rights and responsibilities during treatment

3. Schedule C - Emergency Procedures: Protocol for emergency situations and after-hours support

4. Schedule D - Telehealth Consent Form: Additional consent and guidelines for virtual counseling sessions

5. Schedule E - Release of Information Form: Template for authorizing information sharing with other providers or parties

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

Social Services

Education

Employee Assistance Programs

Non-profit Organizations

Private Practice

Public Health

Insurance

Relevant Teams

Clinical Operations

Mental Health Services

Intake and Assessment

Administrative Services

Compliance and Legal

Quality Assurance

Client Services

Records Management

Privacy and Security

Relevant Roles

Mental Health Counselor

Psychotherapist

Clinical Social Worker

Psychological Associate

Marriage and Family Therapist

Addiction Counselor

School Counselor

Clinical Director

Practice Manager

Intake Coordinator

Mental Health Nurse

Clinical Supervisor

Administrative Assistant

Privacy Officer

Compliance Manager

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Authors

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