Marriage Counseling Intake Form

Marriage Counseling Intake Form Template for Canada

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Key Requirements PROMPT example:

"I need a standard Marriage Counseling Intake Form for my new private practice in Ontario, with emphasis on telehealth services and electronic record keeping, compliant with Canadian privacy laws and including options for both in-person and virtual sessions."

Document background

The Marriage Counseling Intake Form is a foundational document used at the initiation of marriage counseling services in Canada. It serves multiple purposes: collecting comprehensive client information, establishing the therapeutic framework, ensuring informed consent, and meeting legal and regulatory requirements. The form must comply with various Canadian federal and provincial regulations, including PIPEDA and provincial health information protection acts. It contains sections for personal information, relationship status, counseling goals, medical history, and emergency contacts. This document is typically completed before the first counseling session and serves as a reference point throughout the therapeutic relationship. It's designed to protect both the clients' and practitioner's interests while facilitating effective service delivery.

Suggested Sections

1. Personal Information: Basic contact information for both partners, including names, addresses, phone numbers, and preferred contact methods

2. Relationship Status: Current relationship status, length of relationship, living situation, and previous marriages if applicable

3. Reason for Seeking Counseling: Primary concerns and goals for counseling, including duration of issues

4. Privacy Notice and Confidentiality Agreement: Explanation of privacy policies, confidentiality limits, and information sharing protocols

5. Financial Agreement: Fee structure, payment policies, cancellation policy, and insurance information

6. Emergency Contact Information: Emergency contact details for both partners

7. Medical and Mental Health History: Relevant medical conditions, medications, and previous counseling experiences

8. Risk Assessment: Basic screening for immediate safety concerns, including domestic violence and suicide risk

9. Consent for Treatment: Formal agreement to participate in counseling and acknowledgment of understood terms

Optional Sections

1. Children Information: Details about children from current or previous relationships - include if couples have children

2. Cultural/Religious Considerations: Specific cultural or religious factors that may influence counseling - include if relevant to the couple's background

3. Court Involvement: Information about any current legal proceedings - include if counseling is court-ordered or related to legal matters

4. Substance Use History: Details about current or past substance use - include if relevant to presenting issues

5. Violence History: Detailed assessment of domestic violence - include if there are safety concerns

6. Insurance Information: Detailed insurance coverage information - include if accepting insurance payments

7. Telehealth Consent: Additional consent for virtual counseling services - include if offering online sessions

Suggested Schedules

1. Schedule A - Privacy Policy: Detailed privacy policy and information handling procedures

2. Schedule B - Fee Schedule: Comprehensive breakdown of fees and payment policies

3. Schedule C - Client Rights and Responsibilities: Detailed explanation of client rights and responsibilities during therapy

4. Appendix 1 - Communication Consent Form: Specific agreements about email, text, and other forms of communication

5. Appendix 2 - Release of Information Form: Standard form for authorizing information sharing with specific parties

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 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

Family Services

Social Services

Professional Services

Insurance

Legal Services

Relevant Teams

Clinical Services

Mental Health

Administrative Services

Client Relations

Legal & Compliance

Records Management

Quality Assurance

Insurance & Billing

Relevant Roles

Marriage Counselor

Family Therapist

Clinical Psychologist

Licensed Professional Counselor

Social Worker

Mental Health Practitioner

Practice Manager

Clinical Director

Intake Coordinator

Administrative Assistant

Legal Compliance Officer

Privacy Officer

Insurance Coordinator

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