The Art of the Intake: What Every Therapist Needs to Know About Client Records

Let’s be honest—no one becomes a Massage Therapist or Manual Osteopathic Therapist for the paperwork. But when it comes to client intake and documentation, your forms are just as essential as your hands. Consider this your refresher course on everything you should be doing (and probably already are—go you!) when it comes to intake, treatment notes, and client recordkeeping.

Start at Hello: The Initial Intake Form

The client intake form is more than a bureaucratic hoop—it’s your first look at the roadmap of your client’s health. It helps guide your treatment plan and builds a foundation of trust.

A solid intake form should include:

  • Client’s name and contact information
  • Health history: medical conditions, past injuries, surgeries, medications, supplements, and anything else that might impact treatment
  • Terms of treatment and informed consent

And don’t forget: an annual review of the health history and a fresh general treatment consent are considered best practice. After all, a lot can change in a year—new meds, surgeries, or that time your client decided to take up axe throwing.

Before every session, be sure to verbally check in for any health changes since the last visit. This isn’t just good practice—it’s essential to maintaining accurate and up-to-date records.

Building the Client Record

Here’s what a complete client file should include (grab your checklist):

  • Initial intake form and signed general consent
  • Written consent forms for any sensitive areas, as per CMMOTA’s Treatment of Sensitive Areas Policy (and yes, that’s every time those areas are treated)
  • Annual updates to health history
  • Signed consent for third-party billing, if applicable
  • Copies of third-party receipts, if required
  • Treatment notes for each session, including:
    • Date and time of treatment
    • Duration
    • Purpose
    • Techniques used and recommendations given
    • Verbal updates to health history
    • Any other relevant observations
    • Date notes were completed
    • Therapist’s initials or signature
  • A key for any abbreviations used, even the common ones (don’t make future-you guess what “GTPSR-Dx” means)

Treatment notes must be completed promptly. If your memory is relying on what you ate for lunch that day to recall the session—it’s already too late.

Keeping Records Safe (and Legal)

Records are confidential. They can only be released with the client’s written consent or by court order. This includes doctors, lawyers, other therapists, and even Gary from the front desk.

Important note: You cannot charge a fee when providing records to a health insurance company. For all other third-party requests, a fee may be applied—with written client consent or legal order in hand.

Retention guidelines are crystal clear:

    • Adults: Keep records for at least 10 years from the last date of treatment.
    • Minors: Keep records for at least 10 years after they reach the age of majority.

Yes, that means records must outlive you and possibly the client. Long live secure storage.

Digital records must be stored on Canadian servers. Paper records? Locked up tight when not in use. Privacy matters.

Who’s Signing What?

If your client is a minor, a parent or guardian signs all treatment and consent forms.
If there’s a substitute decision-maker involved, they sign everything too. Make sure it’s clear who has authority—unclear documentation invites future headaches.

Sensitive Areas = Serious Business

Sensitive areas require separate, written consent every time they’re treated. This isn’t about paperwork overkill—it’s about empowering your client to voice concerns and protecting you from any misunderstandings. Each new session means new consent.

From a liability standpoint, it’s simply smart. That signature offers real legal weight should a complaint arise.

Final Thoughts

Keeping clear, complete, and compliant records isn’t just good practice—it’s your best defense, your client’s best care, and a mark of your professionalism.

Still not sure your forms are up to snuff? CMMOTA can provide you with samples, and you can always reach out with questions.

Because let’s face it—your hands are magical, but your paperwork should be bulletproof.