Counselling Client Information Form Template for Canada

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Counselling Client Information Form

I need a Counselling Client Information Form for my virtual therapy practice launching in January 2025, with emphasis on telehealth consent and electronic communication policies, suitable for adult clients across multiple Canadian provinces.

Document background

The Counselling Client Information Form is a fundamental document required at the initiation of any counselling relationship in Canada. This form serves multiple crucial purposes: it captures essential client information, documents informed consent, and establishes the framework for the therapeutic relationship while ensuring compliance with Canadian privacy legislation, including PIPEDA and provincial health information protection acts. The document must be completed before counselling services begin and typically includes sections for personal information, medical history, emergency contacts, consent for treatment, and acknowledgment of privacy policies. It's designed to protect both the client's rights and the counsellor's professional obligations while facilitating proper documentation and communication in the therapeutic relationship.

Suggested Sections

1. Personal Information: Basic client contact details, emergency contacts, and demographic information

2. Medical and Mental Health History: Current medications, previous counselling experience, relevant medical conditions, and mental health concerns

3. Consent for Treatment: Client's agreement to receive counselling services and acknowledgment of their rights and responsibilities

4. Confidentiality Statement: Explanation of privacy policies and limits to confidentiality, including mandatory reporting obligations

5. Financial Agreement: Fee structure, payment policies, and cancellation terms

6. Crisis Protocol: procedures for emergency situations and after-hours support

7. Release of Information: Client authorization for sharing information with specific parties (e.g., healthcare providers, insurance)

Optional Sections

1. Telehealth Consent: Additional consent and protocols for virtual counselling sessions, used when offering online services

2. Group Counselling Guidelines: Specific rules and expectations for group therapy participation, included when offering group services

3. Parent/Guardian Authorization: Required when working with minors or dependent adults

4. Cultural Background Information: Detailed information about client's cultural context and preferences, useful for culturally-sensitive practices

5. Insurance Information: Details about insurance coverage and billing, needed when accepting insurance payments

6. Substance Use Assessment: Detailed substance use history, included when relevant to treatment focus

7. Risk Assessment: Additional screening for suicide risk or dangerous behaviors, used in mental health crisis settings

Suggested Schedules

1. Privacy Policy: Detailed explanation of how personal information is collected, stored, and protected

2. Client Rights and Responsibilities: Comprehensive outline of client's rights and obligations during therapy

3. Fee Schedule: Detailed breakdown of service costs and payment options

4. Electronic Communication Policy: Guidelines for email, text, and other electronic communications with the counsellor

5. Local Crisis Resources: List of emergency contacts and community resources for crisis situations

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

Insurance

Non-profit Organizations

Private Practice

Rehabilitation Services

Corporate Wellness

Relevant Teams

Clinical Operations

Administrative Services

Legal Compliance

Quality Assurance

Client Services

Records Management

Privacy and Security

Professional Standards

Insurance and Billing

Intake and Assessment

Relevant Roles

Counsellor

Psychotherapist

Clinical Social Worker

Mental Health Professional

Practice Manager

Administrative Coordinator

Intake Specialist

Clinical Director

Privacy Officer

Insurance Coordinator

Client Services Manager

Clinical Supervisor

Healthcare Administrator

Professional Practice Lead

Quality Assurance Specialist

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Authors

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