Therapy Intake Form

Therapy Intake Form for Philippines

Therapy Intake Form Template for Philippines

A comprehensive intake form designed for mental health professionals in the Philippines, compliant with the Mental Health Act (RA 11036) and Data Privacy Act (RA 10173). This document serves as the initial assessment and data collection tool for new therapy clients, gathering essential information about their mental health history, current concerns, and treatment goals. The form includes mandatory sections for personal information, medical history, and consent requirements, while incorporating cultural considerations specific to the Philippine context. It establishes the therapeutic relationship's foundation while ensuring legal compliance and proper documentation of client information.

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What is a Therapy Intake Form?

The Therapy Intake Form is a crucial document used at the commencement of mental health services in the Philippines. It serves as the primary tool for collecting comprehensive client information and establishing the therapeutic relationship. The form must comply with the Philippine Mental Health Act (RA 11036) and Data Privacy Act (RA 10173), incorporating proper consent mechanisms and data protection measures. It includes sections for personal information, medical history, current symptoms, risk assessment, and treatment goals. The document is designed to gather essential information while respecting cultural sensitivities and maintaining professional standards in the Philippine healthcare context. This intake form is typically used during a client's first contact with mental health services and forms part of their official medical record.

What sections should be included in a Therapy Intake Form?

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

2. Data Privacy Notice and Consent: Statement of compliance with RA 10173 (Data Privacy Act) and client's rights regarding their personal information

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

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

5. Mental Health History: Previous therapy experiences, diagnoses, and family history of mental health conditions

6. Risk Assessment: Current or historical thoughts of self-harm, suicide attempts, or harm to others

7. Support System: Family structure, living situation, and available social support

8. Lifestyle Information: Sleep patterns, exercise habits, substance use, and daily routines

9. Service Agreement: Terms of therapy services, fees, cancellation policy, and confidentiality limits

What sections are optional to include in a Therapy Intake Form?

1. Cultural and Religious Background: Optional section for clients to share cultural and religious beliefs that may impact therapy

2. Educational and Employment History: Optional background information about academic and work experiences

3. Relationship History: Optional information about significant relationships and relationship patterns

4. Insurance Information: Optional section for clients using health insurance or HMO coverage

5. Trauma History: Optional detailed section for clients comfortable sharing trauma experiences

What schedules should be included in a Therapy Intake Form?

1. Fee Schedule: Detailed breakdown of therapy services costs and payment policies

2. Client Rights and Responsibilities: Comprehensive list of client rights under Philippine mental health laws and therapy expectations

3. Crisis Resources: List of emergency contacts, crisis hotlines, and mental health resources in the Philippines

4. Consent Forms: Additional specific consent forms for recording sessions, research participation, or release of information

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

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Free to use

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What is a Therapy Intake Form?

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What sections are optional to include in a Therapy Intake Form?

What schedules should be included in a Therapy Intake Form?

Authors

Alex Denne

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