Initial Intake Form
The purpose of the Intake form is to provide Massage Therapist and Manual Osteopathic Therapist members with health history information needed from their client to mindfully create a treatment plan.
We know that when members take an initial client intake that often it includes both a medical history and written consent for treatment. Examples of these forms can be found in Appendix 31 of the Membership Policy and Procedure Handbook. Remember that it is important to keep both items current. The generally accepted practice is that written consent for general treatment would be provided on an annual basis at a minimum, completing a health history review at minimum annually as we know things can change. That said, members are reminded that part of the pre-treatment, verbal questions should include a change to health history since their last appointment question.
Your client intake form should include the following:
- Name and contact information for the client; and
- Health History including known medical conditions or diseases, past injuries, past surgeries, medications and/or supplements, etc.
- Terms of Treatment and Consent for Treatment
All items contained within a client’s record must have:
- Date of the Record
- Client name
- Therapist’s name
- Name of therapist supervisor, if applicable
The Client’s Record should contain the following:
- Client’s initial intake form, including initial written consent for treatment.
- Copies of written consent for treatment of sensitive areas in accordance with CMMOTA’s Treatment of Sensitive Areas Policy
- Updates to client’s health history information. Documented complete review of client’s health information on an annual basis (minimum requirement)
- Consent forms for third party billing, if necessary, and up to date as required by third party payer
- Copies of third-party billing receipts as required by third party payer
- Treatment Notes including the following information for each treatment given
- Date and time of treatment
- Duration of treatment
- Purpose of treatment
- Notes on treatment (intervention taken by the therapist, any new healthy history information provided verbally, techniques/recommendations applied or offered)
- Any other relevant information to the Massage Therapy session
- Key for abbreviations used in notes whether common or not
Treatment notes must be completed within 24 hours of treatment. The assembly and maintenance of Client Records, Charting, and Treatment notes are the responsibility of the therapist unless specifically stated in either an employment agreement, or a contractor agreement, or a sub-contractor agreement with a third party.
All client records, charting, and treatment notes are considered confidential information. This is known as confidentiality of conversation. Treatment notes may only be released or shared with the expressed written consent of the client, or by an order of a court. This includes release to lawyers, doctors, chiropractors, fellow therapists within the same clinic, other health care providers, health care insurance companies, etc.
A fee cannot be charged for release of client records, charting, or treatment notes when provided to a health care insurance company. A fee may be charged at the discretion of the therapist, for release of client records, charting, or treatment notes to any other third party, provided that the therapist has the clients’ expressed written consent or has been ordered by a court to produce the documents.
All client records, charting, and treatment notes are to be maintained as follows:
In a non-regulated province, or in a regulated province where the therapist is not part of a regulatory college – for a period of not less than 10 years from the last date of treatment when the client is of the age of majority.
In a non-regulated province or in a regulated province where the therapist is not part of a regulatory college – for a period of not less than 10 years from the date that a minor client would have reached the age of majority.
Client Records, Charting, and Treatment Notes are to be maintained for the above time frames, even if those time frames extend past the life of the therapist or the life of the client. Notes are to be maintained in a form that is secure and accessible.
Client Records, Charting, and Treatment Notes recorded in digital form are not to be stored on servers which are located outside Canada. Notes recorded via the paper method are to be kept in a secure location (i.e., under lock when not in use).
If a client is a minor, that person’s parent or guardian shall be responsible for signing any necessary documents either for treatment, consent, or for release of records.
If a client is a person for whom a substitute decision maker has been assigned, the assigned substitute decision maker shall be responsible to sign any necessary documents either for treatment, consent, or release of records.
CMMOTA’s Treatment of Sensitive Areas policy requires written consent for the treatment of sensitive areas each time that a client receives treatment that includes those areas. This policy was put in place to empower the client in their ability to vocalize an uncomfortable situation that may be encountered during a treatment while providing the therapist with the best protection from potential accusations which may be levied against them.
From a legal liability perspective, having your client acknowledge by form of written consent every time, rather than written consent given previously, provides the therapist with a greater level of protection.
