Guest Interview on The Testing Psychologist

Psychologists and counselors who provide testing definitely deal with plenty of paperwork! Managing all that paperwork can be difficult... and it's another one of those things we rarely talk about that creates a lot of stress. 

That's why I'm so glad that Dr. Jeremy Sharp of The Testing Psychologist is now providing resources for those of us who love testing (yup, I'm one of the testing geeks!). He's built a Facebook community, as well as a podcast in order to share resources.

Jeremy recently interviewed me for his podcast and, of course, we talk about documentation! We get into things like what to include in your informed consent, options for storing records, and what to consider when sharing test results and reports with other parties. 

If you have a testing practice, you'll definitely want to check it out. Click here to listen

The "Best of" Series: Creating a Community Among Therapists, Not Competition

You know that feeling when you connect with someone right away? You're able to joke with one another, share similar values, and the conversation is so natural. That's what it was like the first time I talked with Rajani. 

Rajani Venkatraman Levis is a licensed marriage and family therapist with a practice in San Francisco. She specializes in trauma and EMDR and she is very involved in the larger EMDR community. So involved, in fact, that she (along with another colleague) created a Bay Area EMDR chapter. 

You see, Rajani was looking for a community that she could connect with. And when she had trouble finding that community, she decided to create it herself.

In this interview below, Rajani talks about how she created that community, why it's so important for those of us in the mental health profession to support one another, and why there are plenty of clients to go around.

This video is from an interview I did with Rajani in 2016 for the Road to Success Summit, but I really think it deserves to live on beyond the Summit, so I'm sharing with you here:

Rajani is seriously an example of clinical and business prowess. She has built a very successful practice by owning her strengths, being herself, sharing resources, and providing the services that clients in her community need. She is also on a mission to help other therapists do the same... but without offering courses or business consulting packages. She's doing it by creating community. 

If you want to become part of the online community Rajani is creating, check out her latest venture, www.talkingabouttherapy.com.

She currently has an awesome blog series called "Five Minute Magic" which highlights various things you can do in five minutes to improve different things within your practice. And yes, I did contribute to this series, of course! Click here to read my 5 quick tips for improving your paperwork

Clinical Supervision and Notes: How to train your clinicians

clinical supervision of notes

By far, the most common thing I hear from clinicians is that they didn't receive any (or sufficient) training in documentation.

This is a topic that is very important to all of you. I know because you tell me, you read this blog, you watch the videos and I consistently hear the same thing again and again in workshops. 

Since many people who are supervisors are the same counselors who never received training in documentation themselves, they often don't know where to start with their supervisees.

That's what this blog post is for!

I'm going to outline some different ways to review documentation and notes with your fellows, interns, practicum students and trainees. You may not use all of them, especially if you're new to this, but I guarantee some of these steps will give you ideas for where to start or how to improve. 

1. Review files and notes every week (or however often you meet).

It can be tempting to spend time in supervision focused on the more "interesting" clinical content or to address the crisis of the week. However, your supervision time should incorporate training on ALL aspects of being a clinician. 

And that includes getting paperwork done and evaluating how effective that paperwork is.

Spend some time looking through a client's file, particularly if it's a client about whom you're already discussing a crisis or clinical issue. Not only will this ensure all the legal ducks are in a row, but going back to earlier stages in treatment can often provide clinical insight now that you've spent some time with this client.

2. Read through an entire file, not just that week's notes.

This one is huge! Working as a Quality Improvement Specialist in a few different agencies, I noticed that I would often pick up on things the supervisor hadn't... even when they were regularly reading and approving weekly notes. 

That's because the supervisor was focused only one note.

Looking at that note alone, it seemed fine. However, when read within the context of the client's full file (as I was reading), certain things stand out.

For example, if something significant had happened in the previous session and that session's note had identified some follow up that would happen, I was looking for that in the next note. If that follow up was missing I picked up on it right away because it made the client's story disjointed. 

However, the supervisor could easily overlook this because they were simply focused on the one note and whether or not that content was coherent and professional. Not a bad thing, but taking a different approach every few weeks will provide a different context.

3. Practice together, especially in the beginning.

Do you remember writing your first case note? I do. I remember that I had a few samples in front of me and while they seemed great, they all of a sudden seemed completely irrelevant to the note I was writing. So I simply dove in and tested the waters to see what would be approved.

Now consider if my first experience writing notes had been with a supportive and experienced clinician guiding me. I would've had a chance to ask questions, compare things, get different ideas for wording, etc. 

I know what you're thinking... notes are boring and no one wants to spend time together writing notes. However, I've found this to be the opposite! 

One of the things people consistently mention about my trainings is that they enjoy seeing examples, watching me write notes, and writing notes together. They even really like getting feedback on the notes they've written.

However, this is something that is often nerve-wracking for people and it's unlikely anyone will ever ask you for it. You must initiate but I promise you that 99% of the time, it will go very well.

So take the time to review paperwork, practice writing things together, and continue to do these periodically throughout your supervision time, not only in the beginning or not only for people who appear to be struggling. 

You will create much more confident clinicians who are able to focus on what matters most- how to best help their clients. 

Now you tell us! What have you found to be helpful when working as a supervisor. What did a supervisor offer you that provided you the confidence and tools you needed to be successful? Let us know in the comments below.

My 4 Favorite Assessment Questions

Favorite Assessment Questions Therapy

I've mentioned before that clinical assessment is one of my absolute favorite topics, and one of my favorite things about being a therapist. 

I was fortunate that early in my career I was required to complete LOTS of intake assessments and this forced me to become good at two things in particular- time management and asking good questions (not to mention typing and writing quickly, too!). 

So I thought that I'd share with you my favorite assessment questions that I've continued to find useful over time. Many times, asking these questions leads into powerful and detailed conversations about the concerns clients are bringing to therapy

I encourage you to try them out and adjust as much as you like to make them fit with your clientele in each situation.

1) Describe a typical day for you.

I know, I know. The first one isn't even a question! But it's one of the first things I review with clients when they come in and I find it often leads in to getting more details on the way in which their identified problem impacts their every day life. Going through their typical day prompts them to think of things they may not have considered if I simply had them list off general concerns.

By the way, I do actually have them list off general concerns ahead of time in a quick checklist (available in my Paperwork Packet). But this question often leads in to much deeper topics.

Quick Tip: Adjust this for interviewing parents about child clients.

Parents often have difficulty identifying how often behaviors occur in children. It is important to get a detailed picture of this so you can highlight progress along the way, for the sake of both the parent and the child. 

When parents describe problem behaviors, ask how often they occur by going through their day. How often does the behavior occur between waking up and going to school? How often while at school? How often between returning home and having dinner? How often between dinner and going to bed?

This will help you identify times of day that may be more problematic, triggers to behaviors, and also give you a detailed baseline to visit when you want to praise the progress that is being made in counseling.

2) What strategies have you already used to try and solve the problem?

This question is very important to me because it helps us identify what doesn't work, or how to adjust the strategies already used. Most people have already tried solutions on their own or may have reached out to other professionals for help, whether that's another therapist or a religious leader, an acupuncturist, or a psychic.

Dig in to what led them to seeking out those solutions and why they didn't work. Some may have worked up until a certain point or helped with one aspect but could not address the whole problem.

This will often bring up the deeper meaning behind a more superficial problem or identify other areas that impact the problem for which they are coming to therapy. Then you're able to identify how you can best work together, what the focus is, and where is the best place to start.

Lastly, this also a great way to discover your client's resources, network of support, and personal strengths. These are all things you can use within therapy to assist process and progress. 

3) What would you like to get out of counseling? How will you know you are ready to finish?

Somewhat related to #2, I find this question hugely valuable. This is what helps guide me throughout my work with the client because I need to stay on task.

Of course, things may change and new things will come up over time, but knowing the client's goal helps to steer the ship and know whether something should be passed up (perhaps to address later on), addressed head on, and if you may need to take land at one particular problem for an extended period of time.

This is also a way to help clients who are having difficulty transitioning out of therapy. You can point them to their own goals and reasons they would know they are ready to move on. That's why I do document this one specifically, both by asking the client to write this out before seeing me and in my notes for that session in which we discussed it. 

4) Have you ever been arrested?

A little less "touchy-feely" than the above questions, but this question is still one of my absolute favorites that also provides a wealth of information. 

Note that this is different from asking whether or not someone has a criminal record.

This is a really key distinction. The point of asking about arrests is to gather information about potential problem behaviors that may not have resulted in a criminal charge. This also helps to simplify the question because, in my experience, many people do not view misdemeanors or DUI's as a criminal record and will genuinely answer "No." 

This question will be more or less important based on the type of work you do, but it is still an important question to ask every client in every setting. 

Never assume that someone does or does NOT have a criminal record or arrest history based on their presentation! I have had many unassuming people whom I would never predict having a record answer "yes" to this and it has been important for our work together.

For child and adolescent clients, it is important to follow up by asking "Has anyone in the family ever been arrested?" 

Obviously, this can provide information that you would often not receive by simply asking about a criminal record. And, regardless of guilt or charges being made, arrests of loved ones can significantly impact a child's emotions and view of the world. These are important things about which to be aware. 

There are so many things we could potentially review with clients during our intake assessment. 

This is obviously not an exhaustive or required list. But I have found all of these to be very helpful in a variety of work situations, including private practice. Some of them are in my intake assessment that I have clients complete ahead of time, and all of them I definitely review in person. 

What other questions have you found helpful during the assessment phase in private practice, or other settings? Share in the comments below!

Writing a Mental Status Exam

A few months ago I received a question about writing mental status exams (MSE) and realized I've never talked about this! So, here is some direction regarding all things MSE...

What is a Mental Status Exam (MSE)?

A mental status exam is a brief snapshot of a client's presentation. The MSE is meant to assist with diagnosis, capturing and identifying symptoms, but also to create a succinct picture of the presentation at a specific moment in time.

This means that a person's MSE may appear very different at various stages in treatment, and that's perfectly fine. For example, a client experiencing a manic episode will present very differently at the height of the episode than they will during times of mood stability or during a depressive episode. 

I should note that an MSE is always meant to be completed by the clinician who saw the client, and should include a visual assessment (meaning over the phone would not capture many of the applicable sections). 

The MSE is generally more useful for clients with acute, chronic or more severe symptoms. While it can be useful in all circumstances, many sections may not apply to clients with general adjustment or change of life issues. 

When to Use a Mental Status Exam

The most common use for the MSE is during a clinical assessment. The MSE can actually provide a great source of documentation to support diagnoses for clients. If you have difficulty diagnosing or worry about substantiating diagnoses for insurance companies, try using a mental status exam and then make sure DSM diagnostic criteria match up with the identified presentation. 

An MSE is generally completed during the first 1-2 sessions, and then any other time when re-assessing symptoms. 

That might include regular intervals of time, in order to identify progress, or only as needed during the treatment process. It can be helpful to complete one at the end of treatment to highlight any differences in presentation and celebrate growth.

Some clinicians do complete a brief MSE as part of every progress note but I find this unnecessary in most cases. Of course, that is a preference and if using the MSE every time works for you, great! Just remember to include some information about what transpired during the session, as well. 

How to Complete a Mental Status Exam

Like it or not, mental status exams were created to capture dysfunction, not ordinary function. That's why you'll find most of the categories very "clinical" sounding.

For this reason, it is generally acceptable to simply mark "Within Normal Limits" (or "WNL" for short) if there is no impairment found in the identified section. However, this creates that sense of obligation without purpose in documentation that you know I dislike! 

That's why I recommend that if you are using an MSE, then describe each section regardless of the impairment.

And if you don't find this useful, don't do an MSE! Or, perhaps pare down your MSE so that it only includes the sections you find helpful. These don't have to be long descriptions. Remember, the MSE is meant to be a brief assessment, a snapshot. Keep your answers to just one or two sentences, at most. 

Recommended Mental Status Exam Sections

I am listing these alphabetically, in order to keep things simple. However, these are often listed in notes more by level of depth or order of importance. Many sections are often combined so I have either outlined this or included the common names together.

Affect

Different from and similar to mood (below), affect is a bit more descriptive regarding how a client is presenting their mood. For example, affect and mood may both be depressed or sad. The client describes themselves as sad and appears to be so. 

However, affect can also include things like constriction, range of emotion, and appropriate expression of emotion. For example, mood was depressed and affect blunted. In this example, affect is describing the fact that the client exhibited limited emotion, although they may actually be feeling quite depressed. 

Due to the similarities and how these interact, affect and mood are often combined into one section on an MSE "Affect/Mood." I only included them separately here to review the difference between them. 

Appearance

Self-explanatory, this is literally the physical appearance of the client. Note any unusual physical characteristics, grooming and clothing.

Tip: Stay objective here and avoid phrases like "attractive" that can be offensive and subjective depending on the person describing attractiveness. 

Behavior

This is the physical behavior present during your assessment. Here you will note how the client moved and acted physically. This could be something like frequently fidgeting, shaking leg, unable to sit still, or walked very slowly. It may also include things like yelling or crying. 

Concentration

Here you will note any difficulties with concentration, such as difficulty tracking the conversation, frequently getting distracted or going off task.

Insight/Judgement 

A more subjective measure, in this section you will comment on your perception of the client's insight based on the interview. You may note things like how well your client understands the reasons for their behavior or contribution to a problem, whether or not they recognize the severity of a problem, and what is their perception of how to address problems. 

Intelligence/Cognition

Here you can describe the client's abilities based on the information you've gathered so far. In general, this is really meant to capture the more extreme ends of the spectrum, such as significant cognitive deficits or very advanced vocabulary for developmental age. 

Some clinicians will actually test things like working memory briefly during an MSE by doing serials 7's (counting backwards from 100 by 7's), having a client spell "world" backwards. While impairments here may alert you to something, they are certainly not an indicator of actual intelligence.

Memory

You may do a brief test of your client's memory (asking them to remember something at the beginning and then at the end) but then you again have a very low validity picture of memory. It is best to use this section to comment anecdotally on what was noticed during the session. Did your client leave out important details frequently? Have trouble remembering important events or specific periods of time? Also note if they identify any concern about their memory. 

Mood

This one seems obvious and yes, it sort of is. Mood includes common descriptors of how people are feeling and may use traditionally clinical language or more commonly used laymen's terms. These include phrases like depressed, anxious, worried, sad, euphoric, happy, irritable, etc.

Orientation

This is probably the category most commonly used in the medical field and always included in general mental status exams. Orientation refers to how well the client was oriented to person (themselves), place (the setting in which your assessment occurred, as well as their general location), time (date, time of day) and situation (physical and emotional situation). Note that situation is usually but not always included.

This is typically a very brief section, simply noting something like "Client was oriented x4" or "Client was oriented to person but not time, situation or place."

Perceptual Disturbance

This section has some crossover with thought process and content but could be used to highlight things like hallucinations, if that is a common symptom you see. If so, identify the type of hallucination (e.g. auditory, visual, etc.) and any relevant info.

Speech

Another self-explanatory category, here you will consider anything related to speech quality. This includes things like speech impediments, rate of speech, volume, etc. 

Strengths

This category is not always included in common MSE templates, but I always work from a strengths-based and client-focused perspective, so I'm including it here. You can identify strengths you noticed during your meeting with the client, and also ask the client (or parent/guardian) to identify strengths.

Suicidality/Homicidality

Here you will acknowledge your assessment of these areas and specifically note whether or not the client denied these, has a plan, has ideation only, etc. 

Even if your client was noted to be suicidal with a plan, don't feel the need to include extra information here. That will all be in your progress note where you describe your assessment in more detail, along with the identified plan. 

Thought Content

This section captures what was the main content your client presented during your session, as well as any noteworthy content items that came up. This may include delusions and hallucinations, if you prefer not to have a separate category for these symptoms. 

Regardless of things like delusions, this is also the area to include things the client focused on as important. That may be feelings of guilt, preoccupation with a particular topic (video games, sex, a specific person, etc.), irrational worries or even phrases that were repeated throughout. 

Thought Process

While content focuses on what was discussed/presented, process focuses on how the client presented that information. This includes things like ability to think abstractly, connections made as explanation for behaviors or mood, associations and ability to stay on track, flight of ideas, or magical thinking. 

Yes, there may be some crossover here with things like concentration and insight/judgement but this section really pulls those pieces together to describe how the client views the world and themselves.

Create Your Own Mental Status Exam

If you're in private practice then you have the flexibility to use which sections you like, complete an MSE whenever you feel it is relevant, or even avoid it altogether

I recommend you look through the sections and then identify anything you think would be helpful to document during intake assessments, then anything that may be helpful to track over time at various intervals, and anything you'd like to capture at the end of treatment for a more objective view of progress. 

You may find certain sections more or less relevant for different clients, and that's okay. Think about your current clients. If a section applies to at least half of them, then it will likely prove useful to you. If not, then scratch it and just add that in when it's needed.

You can also create an "Other" category for random things that come up but don't fit anywhere else. Simply use that as your catch all and then take note if you find yourself including the same thing over multiple clients. Then maybe it should become it's own category.

You have the power here to make the mental status exam whatever you'd like it to be for your practice. So make it meaningful to you and helpful to your clients. Otherwise, there's no point!

Let us know in the comments below... do you use a mental status exam in your practice?

What tips have you found to make it meaningful and easy to complete? 

5 Counterintuitive Ways to Improve Your Notes

By far, the most common concern presented to me by therapists is note quality. Clinicians are hoping their notes are good, but since no one else reads them or since they receive little training in this area, they actually have no idea if the quality is there.

For content related to writing, I've got sample notes available for free inside my Private Practice Paperwork Crash Course. You can also check out this blog post that has an example of necessary content and how to pare down note length.

Today I'm sharing with you five counterintuitive strategies that will help you improve your notes, no matter what your current quality may be... and they're all things you can try out right away!

1) Take a break

One of the best things you can do for your productivity is to take regular breaks. Whether it's five minutes every half hour, 10 minutes every hour it doesn't matter. The key is that you must schedule them in and take them!

Even if you feel like you're in a place of "flow" and working for over an hour, it is rarely helpful to continue working without a break. Trust me, as someone with ADHD, I know this struggle!

Lucky for you, I've made it a little easier to take a quick five minute break. Why not listen to some music that will help you rock out, give you a dance break, or pump you up for more work? Check out my new playlist on YouTube for some epic songs to keep you going... after a break to rock out or dance: 

Rock Out Dance Out Break From Notes Playlist

2) Reflect first

Taking the time to reflect on your session, your client's progress to date, any struggles you're encountering, etc. will clear your head and help you focus when writing your notes. It doesn't have to be long but pause for 1-2 minutes before your note and make sure you are in the right head space.

3) Plan ahead

You've heard that quote: "Fail to plan and plan to fail." That definitely applies to your notes! Make sure you give yourself enough time to write notes each day, allowing time for other administrative tasks at a different time of day.

Many counselors run into trouble because they forget to plan out note writing time when figuring out their schedule. Even then, they'll often add that time for general administrative tasks including notes. Doing this usually means notes become a last priority, behind answering voicemails and emails. 

4) Read through old notes

I recommend you spend time each quarter looking through your client's file. This will actually make you a better writer because you'll catch things you may have missed or recognize common phrases you like to use in notes.

This review time will also help you see how well you're able to blend sessions together to tell the complete journey your client is taking with you. Don't worry about spending hours on this. Simply plan for one hour each quarter and see your notes grow in quality!

5) Let your client help

Lastly, let your client help you write notes! Collaborative documentation has not only shown to be a faster way to write notes, but clinicians commonly report it also helps improve their note quality. They feel better about the content because it is up to date and their client has helped summarize things from session.

Plus, if your client is contributing to their notes each week, the fear of your client seeing their records is pretty much eliminated. ;)

If you'd like a more in-depth training related to collaborative documentation, consider signing up for my Webinar CE Club. There are already four previous trainings waiting to be viewed, one of them on how to incorporate collaborative documentation. You'll also get access to a new webinar (and CE credits!) each month.

Which of these strategies is the most helpful for you? Which one do you plan to try out this week? Let me know in the comments below!

How to Avoid Writing Notes

Sometimes we just need a little fun! Check out this video for some great ways to avoid writing your therapy notes:

What's your favorite way to avoid writing notes? Share your biggest vice in the comments below. Better yet, share your tips for overcoming these things!

And if you want help catching up on those notes, check out the Paperwork Catch Up Group starting Monday, January 9th.

Happy writing! 

Drafting Your Personalized Note Template

One way I recommend counselors save time on notes is to choose a notes template and stick with it. In my Private Practice Paperwork Crash Course I review five different types of templates you can use and these are basic copy and paste topics you can use across the board.

However, I do get feedback occasionally that some therapists have adjusted the templates and when they do this, therapists tell me the template is much easier to use and much more meaningful to their work... because it's personalized.

So, I thought I'd review all the different components of common therapy notes templates in case you'd prefer to simply pick and choose what works for you. These components all come from the following note template formats: DAP, GIRP, PAIP and SOAP.

I encourage you to check out what sections appeal to you and seem meaningful to your practice. Choose those and create your own therapy notes template that you'll find easy to use every day.

These are simply listed in alphabetical order, with no identified level of importance.

Assessment

This section focuses on the clinical assessment of the client's symptoms, progress, presentation, etc. Here you can add more clinical language and also outline how the session may interact with previous sessions or experiences, as well as highlight things you think may be important to monitor.

Data

This is the same as the "Objective" section below (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes here.

Goal

This is typically at the top of the note and includes whatever goal(s) the client is working on. Rather than making things complicated, simply copy and paste from your treatment plan wording. Keep it simple and direct, but also monitor to make sure your sessions are really in alignment with the goals you are including with each note.

Intervention

These are the actions of you, the counselor leading the session. Whether this is something you did passively (like building rapport) or more actively (like teaching a technique), this section is meant to capture where you directed things and how you responded. If you tend to review or teach techniques, direct clients in certain behaviors or challenge and examine thought patterns, this will be an important section for you to include in your notes.

Objective

This is the same as the "Data" section above (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes in this section. 

Plan

The plan is one of the most important components of any notes template and I recommend you have a Plan section regardless of what other sections you include. This is where you identify follow-up, whether that is for you or the client. Here you can clearly identify how the client may incorporate what was learned in session over the next week. And you will also include when is the next planned session. This is crucial for documenting your continuity of care.

Problem

Similar to the "Goal" section, the Problem is whatever problem area the client identified they would like to work on in therapy. This may be just as specific as a goal, or may be somewhat vague, such as depressed mood or anxiety. Regardless of the specificity, this will help guide your treatment and allow you and the client to know you are on the same page with where things are headed.

Response

This section is the opposite of the "Intervention" section because it is focused solely on the client and how they reacted to things during session. Similar to the "Data" section you will want to include objective information that would be easily seen or heard by anyone in the room. However, if you choose not to have an "Assessment" section, you may also include more subjective responses made by your client as well. Also, remember that refusing to participate or react to something is also a type of response and should be included here. 

Subjective

This section is opposite to the "Objective" and includes information shared or observed during the session that is either subjective to you or to the client. This could include things like a prognosis or an interpretation of a response. It could also include subjective statements made by the client themselves.

So, how does this all look if we put it together in new formats? You'll notice that some sections are similar and I never recommend duplicating your work, so choose what you like best to have a complete note.

Some examples could be: 

PDAP (Problem, Data, Assessment, Plan)

GOAP (Goal, Objective, Assessment, Plan)

PIRP (Problem, Intervention, Response, Plan)

PIRAP (Problem, Intervention, Response, Assessment, Plan)

SOIAP (Subjective, Objective, Intervention, Assessment, Plan)

The amazing thing about being a therapist in private practice is that you get to make these decisions! Don't let it overwhelm you, let it make you a better clinician by personalizing things to yourself and your clients as much as possible. 

One last recommendation is to consider using one format for ongoing notes but a different template for assessment. A participant in my Meaningful Documentation program did this and found it was much easier for her to write the more in-depth assessment note for the first session but then she could take things down a notch going forward. 

Play around with things and see what works for you. Don't make it too complicated but also understand that sometimes creating these systems does take time. However, once you have a clear format for writing progress notes you are able to do them much more quickly and with less mental effort. 

That way you can spend time on what is most important- the clinical work!

Leave a comment below and let me know what you decided if you choose to mix and match. I'd love to hear and so would many of your colleagues!

Catching Up On Notes: An Interview with an Honest Therapist

We've ALL gotten behind on notes. Yes, all of us. 

The problem is that we never talk about it. And the more behind you get, the LESS you want to talk about it. But that makes the problem worse, and so things go on and on until you feel overwhelmed.

That's exactly what I'm talking to Dr. Traci Lowenthal about today. Traci got behind in her notes, and was courageous enough to let me interview her about how she's getting caught up and how she plans to avoid this happening again in the future.

Click below to check out the video and share this with your friends! I guarantee you know at least one counselor who is behind in notes right now, but too ashamed to discuss it. 

Wasn't she awesome to share her experience with us?! 

If you're also behind in your notes but not sure how to start getting caught up, or if you need some extra motivation, check out the Paperwork Catch Up Group

This is a group where you get the practical tips as well as the moral support you need to get caught up and stay caught up on notes. 

And if you have your own tips and tricks you'd like to share, leave a comment below! Remember, you're not alone.

Writing Your Client's Journey: Interview with Jo Muirhead

While blog posts are helpful, sometimes you just want to hear what someone else is doing and model things after them! That's what I'm doing with the regular "Writing Your Client's Journey" series and to kick things off I interviewed a very successful group practice owner in Australia, Jo Muirhead

Jo shares some excellent tips on things like streamlining, creating systems and encouraging your motivation to get paperwork done.

You'll notice some sound distortion in just a few spots but it's very brief and there's a ton of great tips so stick with it! And if you've only got a few minutes to check things out, scroll down further for the interview highlights.

My favorite quote from this interview is early on when Jo says about paperwork and systems, "If you can't learn to love it, you've got to respect it because hating it helps nobody."

In the beginning of her practice, she tried to customize her systems and forms to meet each individual client's need but then found out that wasn't working as her practice grew. So, Jo started to create systems for getting all the mundane but necessary stuff DONE.

Creating a system for yourself makes things more simple and easy. Without these in place, you can easily be distracted from the work you really want to do- your clinical work with clients. 

Prepare for growth by having directions for things written down for anyone who may need it later on (e.g. an assistant or a new clinician). This can save you hours of time... Jo and her team set up one system that turned end of month financials from a 10 day task into a two day task!

Specifically, some tips that Jo shared during the interview are: 

  • Set up a checklist for each task
  • Create a centralized place and system for all tasks
  • Teach a child or a partner (or team up with another clinician) how to implement each task to identify holes in the system
  • Schedule everything (especially notes and accounting)
  • Use LastPass to manage all your passwords for every site that requires a password

Important things to focus on streamlining: Intake and discharge

Important things to keep up with regularly: Notes and bookkeeping

Jo also had a great tip for those times when you become overwhelmed by a task. Ask yourself, "What could I have done to make this easy on myself?" Then focus on changing that one habit to improve things in the long-term.

And the big payoff from putting in all this work? Once you have a clear idea of how long it takes you to complete a task, you can decide if it will be worth delegating and, if so, you know what to expect from that person!

Feel free to share in the comments below. What have you found helpful for simplifying paperwork and other administrative tasks? 

Want to learn more about Jo and the coaching services she provides for others? Click here to learn more!

Paperwork Tips from Experienced Therapists

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I recently took to the Blissful Practice Facebook Group for some advice on documentation from those in the trenches... you! It was great to see all the tips everyone put together and also highlights that it is so important to find the paperwork practices that are meaningful to you

Here is some of the great information I collected from this fabulous group of therapists:

Use an Electronic Health Record (EHR)

Alicia Taverner, Owner of Rancho Counseling, and Sandy Demopoulos both say that using an electronic health record (EHR) has been instrumental in improving everything related to documentation. Alicia uses Simple Practice and is able to dictate case notes on her phone using the app, which helps her stay up to date. She notes it is a "game changer." Sandy uses Counsol, which offers many features, including virtual therapy rooms. 

Stay On Top Of Notes with Productivity Hacks

To help keep up with notes, Charlotte Hiler Easley schedules 30 minutes in between client sessions. That way she has time for self-care and notes. Jane Johnson Wall uses TheraNest, which helps her stay up on billing. She says this is one of the most important things to keep in mind because it is so easy to get backed up and that can result in lost revenue and lots of headaches! 

Shanna of Happy Nest Therapy has also made a point to stay on top of notes. She says she created a schedule and a note template early on and this was hugely impactful. Since she took the time to make this a habit in the beginning of her private practice, she is now always able to keep up with notes, writing notes within 24 hours of every session. She also keeps a call log and reviews that each month to insure she is documenting everything outside of regular sessions. 

Erin Gibb also created a note template based on common things she wrote and then takes some notes during session. She then sets a timer for five minutes after each session and makes sure to only spend that amount of time on her notes. That way she is done quickly but she is keeping the quality content. 

And Raquel Buchanan, also of Rancho Counseling, adds that she notices many clinicians fall behind because they are not ending sessions on time. She sticks to a 50 minute session, then 10 minutes of note writing. Raquel also notes that you can use this additional time write notes with your client, too.

You can also write intakes with your client during the first session, as Traci Lowenthal of Creative Insights Counseling does. She says this has been "miraculous" for keeping her up to date with bigger paperwork tasks. And when she gets behind on things like notes, Traci sets a timer for 20 minutes 1-2 times a day to make sure she is working to catch up.

Document the Little Things

Nicol Stolar-Peterson of Therapist Court Prep recommends two tips based on her experience as an expert witness who is often testifying in court: 1) Document your client's appearance, including what they wear. This way you are able to quickly and objectively note an changes that occur over time. 2) Time stamp everything. Document and time stamp when clients disclose new or significant information, when they sign or ask about documents or policies, etc. She notes that "once I start giving the exact times of disclosures, I find that attorneys back off quite a bit."

Use Your Experience as a Resource

Tiffanie Trudeau of Counseling Alliance is a former Clinical Director at an agency. When she opened her private practice she decided rather than give in to the temptation of forgoing all the agency documentation, she would take that foundation and use it in her practice. She is consistent with her paperwork practices, whether her client is pro bono, insurance or private pay. She even used one of my favorite quotes in her advice: "if you didn't write it down, it didn't happen."

On the flip side, Shirani Pathak of the Relationship Center of Silicon Valley recommends keeping things simple. Maintaining her previous agency's standards was difficult in private practice and so she made time to whittle down to just the necessities. Now she is confident that she's meeting ethical standards but it is also easy for her to keep up with everything.  

Being on top of things is even more important as you start to supervise others. Group practice owner and coach Sherry Shockey-Pope recommends documenting when you discuss cases with supervisees. Write down your discussion and then your follow up plan with the client... and then actually follow up!

Communicate With Your Clients

Similarly, Kate Pieper says that clients have commented on her follow up with them. She makes sure to note at the end of each session what they will be addressing in the next session. Kate also recommends not being afraid to take some notes during counseling sessions. She is casual with this and that makes her clients feel comfortable, too.

Maaliea Wilbur of Therapy Works wraps things up nicely with this advice: "Do it!"

Lastly, Amber Hawley of Fremont Counseling Services has one last tip for you... sign up for my Webinar CE Club! I swear, I didn't tell her to say that ;) But it does highlight the importance of staying connected with colleagues and making room for this type of discussion so that you can always have the best resources. 

Feel free to share your tips below in the comments!

Credit Cards: Your Questions Answered

One thing I don't provide in my paperwork packet is a form that allows you to write the client's credit card number and save it in a file cabinet. How come? Because there are plenty of more secure ways to capture your client's credit card info.

I actually receive quite a few questions related to this so I was very happy to meet Emily from Ivy Pay. She is a therapist on the operations team for a company that provides convenient credit card processing for therapists who may not have other means, such as an EHR. Since IvyPay is specifically designed for counselors, I decided to ask her some of the common questions I receive and let the experts explain for us...

1. Is it okay to keep a client’s credit card number on file so I can bill them regularly?

It’s definitely okay to keep a client’s credit card number on file so that you can bill them regularly. How you maintain those records is what really needs to be kept in mind.  Previously, many folks kept client credit card numbers on file by taking a photo copy of the client’s credit card, or jotting the credit card details down on a piece of paper and storing this in what many deemed a secure manner for the time, such as a lock box. However, with new technologies and updates in banking security this is no longer a secure method of securing financial information. Therapists who do continue to store their client’s financial information in a non-secure manner are at the highest risk to be exploited by hackers which as covered entities would result in a breach in HIPAA. And ultimately, therapists are taking on the liability risk of the credit card information getting leaked and client’s cards being used fraudulently, which is an avoidable burden.

2. What type of security is required for keeping a credit card number on file?

Anyone who keeps a credit card number on file has to comply with PCI DSS (Payment Card Industry Data Security Standard). PCI compliance involves a lot of nuances that are implemented to protect cardholder data (such as maintaining a secure network, protecting cardholder data, maintaining a vulnerability program, implementing control measure, testing security systems and security policies)… in other words a lot of jargon. To avoid dealing with all these security standards, it’s best to outsource to a third party company or service that takes care of PCI compliance for you.

3. Do I need to make sure my credit card processor is HIPAA compliant?

It depends on how you are using the credit card processor. While financial transactions in and of themselves are exempt from HIPAA, if you use additional features that are part of many payment processors such as text receipts, this is then no longer exempt.  As a covered entity it’s important that the payment processor you use doesn’t violate HIPAA. There are a few guidelines that are helpful to keep in mind when selecting a payment processor.

1. Make sure your payment processor isn’t sending receipts via text. Text is not a secure technology, and since receipts contain PHI, they need to be sent via a secure method.

2. Sign a BAA with your processor. If you are storing any PHI through an online provider, to comply with HIPAA make sure you have a BAA signed.

3. Make sure any stored credit card numbers are secured in a PCI compliant manner.

Always remember that even if you have a BAA, if you are not using a service that’s designed to be HIPAA-compliant from the ground up that the provider might release a new feature that could violate HIPAA and you’d be responsible. In essence they are not guaranteeing you that their product roadmap will continue to stay HIPAA-compliant in every respect.

Also, even with a BAA, therapists are still held responsible to be using the service that better protects patient privacy and confidentiality if there’s minimal cost in changing to that service. So it’s important to be aware and keep in with the latest and most appropriate options.

4. I know plenty of therapists who still collect credit card numbers for paper files, are you saying they’re not being ethical?

When you store credit card information for a client it’s important to complete a risk analysis to take a look at how you are storing that information. The best way to store credit card data for recurring billing is through a third party processor that has a secure credit card vault and tokenization provider. When this is in place the card data is removed from your side and a token is returned so that you can continually bill your client for each session while the data is obscured. Storing credit card data on paper in a locked box does not provide the same precautions or level of security.

When you are storing a client’s credit card information it’s also important to tell the client in the informed consent how this information is being stored. It’s helpful if your processor already has this consent designed in, so that’s one less step for you. Ethically, a therapist can determine how their practice works - including if they are going to keep client credit cards on a paper file. However, therapists should be protecting all client information including financial information, in the utmost secure manner. With the ease of technology now, paper files in a lock box is no longer considered the most secure option available, and therefore maybe not the most ethical option either.  

5. Why do I need to pay credit card processing fees?

Think about all the ins and outs of maintaining PCI compliance that has already been talked about. The payment processor is providing that service of mitigating those risks, so you don’t have to.

6. Do most clients really want me to keep their card on file?

Yes! It’s beneficial for not only you but it’s also beneficial for the client. The client doesn’t have to remember to bring a cash or check, and can instead use the form of payment that they most likely use in the rest of their life. In a world that’s full of many means of technology - the therapy room is one of the last few places where credit cards has not necessarily become common hold for clients to use. Both therapists and clients can welcome this change when a few guidelines are met.

7. Can I use a card on file to bill clients for no shows?

This is one of the big benefits of having a client card on file - but is also one that needs to be looked at from an ethical standpoint. What needs to be kept in mind is making sure the client is made aware of your payment and cancellation policies upfront so that the client isn’t surprised when you bill them for a no show. With that said, once informed consent and policies have been discussed, having a card on file is a convenient way to collect fees that may otherwise be lost.

There you have it! Some awesome answers that explain all that complicated credit card HIPAA stuff :)

As mentioned above, always be sure to review any payment expectations with your clients as part of the informed consent process. I also recommend having a statement in your Services Agreement that clients initial or sign, particularly if you plan to charge their credit card for no shows or cancellations. 

Remember that if you use a payment processor through an EHR, you are likely covering all these bases, but it's always good to check. For those of you using paper forms and a separate payment processor, you may want to check out Ivy Pay. It's a convenient way to meet all these expectations without needing a card reader and without having the liability of collecting credit card info yourself. 

Clients put their cards on file with you via the Ivy Pay app, so it’s just a push of a button to take payment. Ivy Pay works with debit, credit, HSA and FSA cards and is tailor-made just for therapists. So it’s HIPAA-compliant, designed for the unique clinical model and code of conduct of therapists. It’s even been uniquely designed to not reveal the therapeutic relationship all the way down to the bank or card statement. For a limited time, get started with $1000 of free charges. Learn more about Ivy Pay here.

Please note that I do not receive any commission or compensation from Ivy Pay for this post. I merely think it is a helpful resource :)

Another helpful resource related to credit card payments is a very affordable course through Person-Centered Tech. It's called Credit/Debit Cards and Electronic Payments in Mental Health Practice: Regulatory and Ethical IssuesYou can click here to check it out.

Feel free to post any questions below!

Prepare Your Records for Release

Releasing records is an intimidating issue for many counselors and therapists. And while we hear a lot of rhetoric on the topic, many counselors are not clear on legal and ethical expectations and end up making poor judgment calls because of that.

A common scenario is that a client requests their records and a counselor automatically refuses to release the records, stating confidentiality concerns. While these concerns are valid, that is not following the law within the United States. Clients do have the right to access their records. From their physician. From their physical therapist. From their mental health therapist.

There are some exceptions and those differ slightly among state law; however,  those exceptions are typically in more extreme cases and require the therapist to prove that access to the records would cause significant harm. Furthermore, these laws still often allow access of the records to someone the client designates.

Does this mean that therapists then release records automatically any time a client makes such a request? Not necessarily. 

The most common practice is first to talk with your client about the purpose for the release. Determine what it is they are hoping to gain from releasing or accessing their records. Oftentimes, this discussion will help the client identify that they actually would prefer a treatment summary from the counselor.

During this discussion with your client it is important to highlight anything that could potentially be misconstrued or misinterpreted if released. However, there are many times when the client still requests the records and the therapist is required to release them. This can be an unsettling discussion for many therapists and that's why I encourage you to consider these scenarios ahead of time, before any complicated situation arises.

I have some strategies you can use to make releasing your records (if necessary) a much less stressful experience:

Think about your client viewing their notes

When writing notes, treatment plans and assessments, work under the assumption that your client will one day view these. This practice helps you to keep language more objective, strengths-based and to the point. 

This does not mean you hide important details or only write the positive things about your client. Keep things honest and real. Your ethics require you to document what actually happened as well as your professional assessment of the client's situation. However, there are often minor tweaks that therapists will make when considering their client actually reading the note and this will improve the objectivity and clarity of your notes.

Think about and discuss your policies

It is important to make sure your policies for releasing records are outlined in your informed consent document... and that you review this with your clients at the outset.

I do not recommend saying in your policy that you will NOT release records because this is not a practice you can legally uphold, except in special circumstances. Instead, note that you will discuss with your client the reasons for the request and make recommendations accordingly. This encourages collaboration should your client make a request at some time later on. 

Also, you can choose to charge for things like making copies, time spent writing a treatment summary or time consulting with other professionals on behalf of the client (such as their attorney). However, if you don't have these charges outlined in your Services Agreement then you may end up spending money and time without reasonable reimbursement. 

In my paperwork packet available for purchase, I make sure to include these things, along with a more in-depth court policy provided by Nicol Stolar-Peterson, LCSW BCD from www.therapistcourtprep.com. If you already have a paperwork packet but are looking for a court policy to add on, you can purchase that on her website for a very reasonable $37. 

Have the insurance conversation

Lastly, if you have clients who are being reimbursed by their insurance company or if you contract with their insurance company, make sure they are aware that all records can be accessed by the insurance company. Like it or not, by allowing a third party to pay for services, clients are also allowing a third party to check up on those services

That also means that you need to consider how that relates to your records. For example, many therapists will downplay client symptoms in an attempt to avoid stigmatizing their clients. However, to an insurance company that makes it seem as though your client doesn't need the services you're providing. FYI, it's also considered fraud to either "downgrade" or "upgrade" your client's diagnosis. 

That's why a basic, easy to remember rule with documentation is to always keep things honest. 

However, if you're looking for help specifically with how insurance and your paperwork connect, you can check out my new on-demand training The Counselor's Guide to Documenting for Insurance. There are so many things to think about with your work, let's make paperwork as stress-free as possible!

Do you have any other tips on what to consider when preparing your records for release? Any tips from past experience? Feel free to share in the comments below!

Resources for Online Counseling and Paperwork

As online therapy becomes more popular and mainstreamed, I see a lot of questions popping up in online forums. Counselors are looking for resources, answers to questions about HIPAA, and general pros and cons before taking the leap into online counseling. And now that I am also providing therapy online I had to make sure I was knowledgable about some of these issues.

I've been fortunate enough to connect with many other therapists and businesses who provide resources in these areas so I put this post together in order to share that knowledge with you! Below we'll look at everything from what your options are (there are likely many more than you think) to what to consider ethically and how to document... of course

Please note that all resources listed below are recommended at your discretion and I do not have an affiliate relationship with any of the recommended sources.

Online Options for Counselors

Video therapy using your own practice

The most seamless transition is to use video software to conduct therapy with your own clients online. There are many services out there that provide HIPAA secure video conferencing tools so you can do this and remain compliant with security standards. 

This type of counseling is very similar to the service you provide in your office but your clients may be in a different town or even overseas. I won't get in to the myriad of guidelines around who you can see online but will say that in general, you are limited to clients in your state and need to know your own state laws. 

There are a few different resources video conferencing but the one you should absolutely NOT use at this point (if you're in the U.S.) is Skype! For a service to be HIPAA compliant, it must provide you with a Business Associate Agreement (BAA) and even Skype for Business is not providing that currently, so it's a no-go. 

For video conferencing you can either sign up for an account that only provides the video or you can sign up for a service that integrates the video with a waiting room and even with your notes and forms for a complete EHR. Obviously, pricing varies greatly based on how much you want from the service but you can check out Vsee, Counsol and WeCounsel

Contractor for an app based video service

A new wave of therapy has arrived and that's video therapy using apps on your smart phone. Much like video conferencing with your own clients, you simply log in to an app on your phone rather than using a service on your computer.

These apps differ in that you typically contract with the app's company and clients are referred when seeking that specific service. The barrier to entry is very low with these services since you don't pay a membership fee. Once you're included in the listing and a client chooses you, they pay the company and the company pays you a pre-determined rate per session.

Since this system uses a contractor-based model, this is typically only available to licensed counselors and therapists. The fees are also lower than general private practice fees but the risk is very low in that there is almost no overhead for the therapist, other than having a smart phone and a quiet place to conduct a session. 

Current companies providing this service (which can also be a great referral source for potential clients requesting lower fees) are Maven and Level Therapy

Contractor for a text-based therapy service

Another form of therapy rising is email or text therapy. More similar to email than texting, this type of service allows clients to send secure messages to a therapist based on whatever scheduled is determined. That may be short, daily emails or longer emails once a week. The therapist then replies on a regular basis.

While this form of counseling may go against what we've traditionally learned about the therapeutic relationship, research is finding that it can be quite effective. Obviously, this is not the recommended method for dealing with crisis scenarios, significant trauma or suicidal clients (to name just a few). However, for many people who are used to online text communication this is a great tool.

Personally, I find the opportunity to interact with clients throughout the week more helpful than the traditional method of limiting conversation to 50 minute blocks. I can encourage people to check in if they have an important meeting or if something unexpected happens and we're able to problem-solve in the moment, rather than discussing it possibly a week later. 

While you could certainly provide this type of service on your own using personal (and secure) email, many therapists are using online services and apps with clients. There has been concern about certain companies and their ethics but places to find this type of service are BetterHelp and TalkSpace. You can also use a (FREE) service like Signal to text clients securely without using your regular phone texting or messaging settings.

What to Consider

Ethics

Most of us first consider the ethical concerns with online counseling and our brains automatically go to the topic that has been of utmost importance since day one of our training- confidentiality. Many therapists are concerned with privacy and how "open source" things seem online. And while there is always risk in any interaction (yes, even traditional face to face), there are many ways in which online services are generally secure. 

The most important thing is to 1) Understand what risks there are with providing therapy online and 2) Inform clients of those risks, along with other general information related to therapy. This topic could be an entire graduate course so I won't attempt to cover everything in this little subpoint but those are the first things to consider. 

Here is a great article from Zur Institute outlining how to conduct a risk analysis (it's not quite as scary as it sounds), what to consider with email and how HIPAA relates to all of this. 

Practicality

Your time is valuable and using email can both save and hurt your time management. Email is great for things like quick notices about appointments but it does leave the door open for more communication. What if your client happens to email very personal information? What if they write a very long email and expect you to read it outside of session?

These are things you must consider with online because whether or not you use text-based or video-based counseling, clients are more likely to email you when your relationship is largely online. Make sure you have very clear policies and procedures around this and have reviewed those with clients from the outset. 

Also, consider your time and resources and how that will be a fit for therapy online. This will help guide you in integrating online counseling services into your business plan and making sure it creates more ease rather than more stress in your practice. Make sure you allow yourself time for training or research before jumping in and definitely make sure you've updated your paperwork prior to starting with clients. 

How and What to  Document  

Aside from your regular private practice forms and policies, if you provide online counseling you'll also want to consider some extra things when it comes to paperwork. 

Informed Consent  

Some states require a separate consent form for online services. And if you provide services both online and in the office, you want to make sure you outline the differences in these types of therapy. Some things to include in your consent form are:

  • What happens if the client's needs increase beyond what can be ethically provided online
  • Procedures to follow in case of poor connectivity or internet outage
  • Procedures you'll follow if you feel your client is in any danger
  • Communication outside of session
  • Expectations for online interaction and the importance of checking in regularly

Emergency Procedures

More specifically, you want to consider how you will respond to clients in emergency situations since you may not be physically located near them. Make sure you have your client's home address, phone number and emergency contacts. Identify the local police and nearest hospital in the area and keep that number handy with your client's info. 

Making sure you're prepared will help you to be more confident about the services you provide and ensure you can keep your clients safe when needed.

Resources You Must Follow

There are many resources for therapists who are providing treatment online but here are some of the top ones that I recommend:

Person-Centered Tech

Roy Huggins is a licensed counselor and also a "tech guy" so he did everyone in mental health a favor when he started Person-Centered Tech. I recommend every therapist sign up for his newsletter. Roy is great about staying up to date on topics like cell phones, Google apps for business, changes to HIPAA, and everything else you have questions about that no one seems to provide a good answer for.

He also offers an affordable membership where you can have access to him for weekly office hours and provides one on one consultations if you just have a few questions while setting up your private practice. Lastly, he provides CE credits for counselors and therapists for reading some of his articles or taking his courses. I am anxiously awaiting his approval by APA so I can collect some of these as a psychologist ;)

Online Counselling Podcast

Yes, I spelled that correctly! Clay Cockrell is a U.S. based counselor who provides therapy online and started a podcast to talk about the many issues that arise as a result. He's had some great guests from around the world who discuss new techniques and strategies, legal concerns, tech issues and more. He also runs the Online Counselling Directory where you can list your online therapy practice for a monthly fee.  

Telemental Health Institute

There are many places where you can obtain CE credit and learn about online counseling services but this site has just about everything you need for training. You can do an entire certification program or take courses piecemeal. Certification is not required by most states but does reflect a level of training, so consider what is best suited for you.

Now what to do...

I hope this article arms you with the tools you need to determine if providing therapy online is right for you and your clients and that you feel better prepared to tackle this new arena. While online counseling isn't appropriate for every client, it can help so many who are unable to leave home, live in rural areas, or frequently travel for business. 

Let's continue to support one another in these emerging areas so we can increase the services offered to the public. Comment below if you have additional resources to share and bookmark this page to reference when those questions come up again!

How My ADD Helped Me With Paperwork

Believe it or not, I was recently diagnosed with ADD. The reasons I was never diagnosed before now are clear. I've always received very good grades, was a genuinely good kid who never caused any trouble, am generally a responsible adult and... I've always been great with paperwork at any job I held.

While receiving the diagnosis was a huge relief for me to explain reasons I've had difficulty with many other areas of life, I began to question how I've been so successful with documentation. Yes, ADD looks very different in each person, but paperwork is supposed to be an almost universal problem for people with this diagnosis! How come it was never a problem for me?

After reflecting on this for quite some time I realized that many aspects of my ADD actually worked to my benefit in completing therapy notes. For real. Let me explain.

Below are some common problems associated with ADD/ADHD that I found I have been using to my benefit this whole time:

Procrastination

Now, this may seem really counterintuitive, but the fact that I regularly (meaning, ALWAYS) procrastinate pushed me to create very firm deadlines for myself when completing paperwork. I know that I can put something off for a really long time. And in my early years as a therapist, I actually had very little supervision regarding documentation, so it was up to me to create deadlines or become extremely backed up. 

While it wasn't easy, I focused on discipline and made sure that I scheduled in time for writing notes and completing assessments. I knew if I didn't schedule it, something else would inevitably take up that time and then, as described in the next reason, I would not be able to produce a quality note. 

Poor Memory

To put it bluntly, I have a horrible memory. So poor, in fact, that if I didn't write my notes within 24-48 hours, I would never be able to write them at all. The sooner, the better for me... and everyone else!

However, I do NOT write notes in between sessions. That just never worked for me. I need the break in between because I've just spent a good amount of energy keeping focus on my client and I need to recharge before the next one.

I either write notes in the session or the following morning, before starting the rest of my clinical day. That way I am able to feel ready for the day ahead and close out what was pending from before... and know it's accurate.

Hyperfocus

Here's where I truly used some ADD traits to my advantage. As many others with ADD/ADHD, I am able to hyperfocus for very long periods of time on things that are of interest to me. So, if I don't write notes in session, I write them in large chunks. That means I rarely sit down to write notes for 10-15 minutes. It's usually more like 45-60 minutes of getting everything done at once.

This means I don't have to pull attention away and I can get in the zone for writing. And because I know that distraction is around every corner, I'll often close my door and shut off things like email during these times.

I create an environment that encourages me to hyperfocus on the task and get it done.

Enjoyment

Some of you may be thinking, sure you can hyperfocus if you like something, but what if you don't like a task... like writing notes?! Well, the key is to find something about it you do like. If you've taken my free Crash Course, you know I talk about creating meaning in your notes and preparing yourself for writing notes.

I literally choose to enjoy the task. First, I know it's a really important thing to do and that helps to motivate me in the beginning. Secondly, I look at writing notes as an opportunity for me to reflect on the clinical work. I view it as a time for me to sit back and see things from my client's point of view or to make sure I'm staying on track with our overall goals. 

It's never a time to just sit down and write notes that mean nothing. This is the time for me focus on my client's session one last time and make sure I've closed any open doors. 

Tips for Dealing with Paperwork for Counselors with ADD/ADHD

Maybe some of the things I've described above help you to see things a little differently or give you some helpful tips to try. But there are plenty more ways to deal with paperwork if you're a therapist with ADD/ADHD. You can also try some of these strategies below:

  • Choose a time that works for you. Make sure the time you're writing notes works to your strengths. For example, I focus better in the morning so that's when I'll write notes... or blog posts ;) 
  • Get accountability. It's scary to admit to another professional that you've gotten behind in paperwork. However, all of us therapists know that talking about something when we feel fear and shame is the best way to overcome those feelings. Even if it's simply shooting me an email, tell someone about the help you need.
  • Incorporate exercise or movement. If you tend to have difficulty sitting still for long periods of time, don't! Write a note, then do 10 push ups or squats. Write another, repeat. I've done this when reviewing paperwork for other people because it keeps me engaged and helps me focus.
  • Try collaborative documentation. If writing notes is a significant point of stress for you, write as much as possible in session with clients. This accomplishes a few things... it will actually help you to be more engaged in the process because your client is there and you're doing what you love- interacting with clients. It will also ensure that your notes are actually done before your client even leaves. No more worrying about procrastination!

While I want this post to provide you with some very practical tips you can implement immediately, I also want it to provide you with hope

I have been surprised by the number of therapists who tell me they have ADD/ADHD. Now, this could be due to the fact that I specialize in an area likely to cause trouble for counselors with ADD/ADHD but it has shown me there are many of us experiencing the same struggles.

You are not alone. And there are plenty of resources out there to help you. 

Consider doing things like bookmarking my Resources page so you have an easy place to reference helpful thing you may need later on but know you won't be able to keep track of today. Or check out my ebook Workflow Therapy, which compiles all of my time management and systems blogs into one place so you can have an easy resource for organization. 

If you're a licensed counselor or therapist, you may also want to consider signing up for my Webinar CE Club, which provides you a guaranteed CE credit each month simply for watching my webinars and completing a quiz. No more worrying about searching for continuing education classes at the last minute! Set yourself up and be prepared.

There are many other tips and resources I could list here! But I'd love to hear what other things you've found helpful for dealing with ADD/ADHD as a therapist or counselor. Share in the comments below and let's show our support for one another. 

Writing Therapy Notes for Insurance

Maybe you've looked through some of my resources and have wondered "but does this apply to insurance?" Well, this post is for you!

While notes don't generally need to be that different when taking an insurance company into consideration, there are certain things you want to make sure you have covered. And, if you contract with Medicare or Medicaid (Medi-Cal here in California), you need to follow these tips to the tee! Yup, those two are a little more on the stringent side when it comes to documentation.

Let's take a look at what an auditor is looking for when reading your notes! Oh, and did I mention I used to do that for a living? So yes, I know a thing or two about what insurance is looking for in therapy notes ;)

  1. Have you addressed each condition listed? This means if you identified more than one diagnosis or problem, you need to make sure you're addressing them both in some way. That could mean collaborating with another provider (especially with things like substance use) or simply having two different treatment goals to cover each area. The key with paperwork and insurance is always that you can't leave the reviewer with a cliff hanger. So, if you mentioned that your client has both anxiety and depression, outline how you're addressing both these issues. Don't leave them wondering or looking for more.
  2. Did you accurately separate out what may be different problems? There are many reasons for behavior and we all know that diagnoses can present very differently in different people... and many diagnoses have overlapping symptoms. Insurance companies expect you do a thorough enough assessment early on so you can differentiate among these things. For example, is your client having trouble sleeping, trouble concentrating and isolating from their spouse because they are depressed or because they have a substance use disorder? You need to be able to identify a clear why for what you're doing with this client, and that includes an understanding of what is leading to their reason for seeking treatment. 
  3. Did you justify your diagnosis? Every insurance plan requires a diagnosis for reimbursement. This is where many therapists end up causing harm for their clients... and getting themselves in some ethical (if not, legal) trouble. It is your job to provide an accurate diagnosis based on your clinical assessment. What does this mean? NO UNDER OR OVER DIAGNOSING! If your client truly has an Adjustment Disorder, go ahead and list that. But if they actually have more significant symptoms that meet criteria for a Major Depressive Episode, it is fraudulent to give them a "lesser" diagnosis. Likewise, if your client has some difficulty and comes to see you for self-improvement but doesn't actually meet the criteria for any diagnosis, you should not inflate their symptoms to meet the criteria just so they can be reimbursed by their insurance company. And let me tell you from experience, it is pretty easy to notice when a clinician is over or under diagnosing... so just keep things clean and diagnose based on what you see. 
  4. Do you have a plan for how to address this client's problem? It's not enough to identify a need and then start therapy. A reviewer wants to know that you have a plan for how to treat this specific problem. You don't need to write a huge treatment plan or outline every possible intervention you'll provide but you do need to outline how you see therapy progressing. If you can do that with an estimated timeline, even better! And if writing a treatment plan seems overwhelming to you, I offer a free treatment plan template in my Private Practice Paperwork Crash Course.
  5. Is your plan something the insurance company should pay for? Any time you have a third party paying for a service, they want to have a say (click here to learn more about what that means for you as a counselor contracting with insurance). And specifically, insurance is looking to make sure that you are providing a needed and professional service that is appropriate to this client. Let's break that down some more... 
    1. You're providing a therapeutic service that requires a Master's Degree or higher. I like to call this the "Grandma rule." Basically, no insurance company wants to pay you to do something someone's grandmother could do for them. Think things like "active listening," "building rapport," and "providing empathic support." These are all wonderful things and are fine to include in your notes. However, when they become the only thing in your notes, a reviewer starts to question your services, because these are things almost anyone without a Master's degree can do. My grandmother is wonderful and when I talk with her she actively listens, shows empathy, and holds space... and she's not providing me counseling. She's talking with me as a close relative. So, show the insurance company you can do all those things plus the awesome stuff you paid all that money to your grad school to learn.
    2. Even if you're doing a fabulous job outlining your clinical work, make sure not to overlook the fact that this service also needs to match your client's needs. If they have a substance use problem, are you trained to address that? Are you providing a reason for using EMDR? Unfortunately, there are therapists out there who will see any and every client who calls simply because they are desperate for money. Insurance companies know this and don't want you to waste the client's time treating them when you're not well-equipped. 
  6. Have you identified how the client is progressing or why they aren't progressing? Each week, you'll want to evaluate the progress your client is making in their treatment plan. This doesn't need to be time-consuming and doesn't even mean you need to look at the treatment plan each week. However, it does mean you can't abandon the treatment plan. I often see that therapists write wonderful weekly notes, none of which identify whether or not the client is actually making progress on the goal they identified and none of which make a lot of sense when put together week by week. Check in with your treatment periodically to make sure your notes flow with it. Mention progress in notes, even if it's a lack of progress... that still shows you're following the plan and adjusting as needed.
  7. Do you have a specific maintenance plan? For clients who are improving but still need some assistance, insurance wants to see that you have a clear plan for maintaining the progress made and weaning the client off treatment. I know, I know... this is what many therapists dislike about insurance, the fact that it dictates the end of therapy. However, if you can provide a reasonable expectation for the end of treatment and clearly outline why each step is needed, your client is more likely to be able to continue with you.
  8. Overall, are you following the insurance company's definition of medical necessity? In a nutshell, insurance wants to see that you have clearly shown the client meets medical necessity and are following their protocols related to that.

Sure, there's more to writing therapy notes for insurance companies but that definitely covers a lot of the big areas. If you want more help with writing notes or with documentation in general, check out my upcoming workshops and programs.

Let me know in the comments if you have any other tips or what was your biggest takeaway!

  

The Comprehensive Note Writing Guide for Therapists

I've written quite a few blog posts on notes over the past few years. Side note: In case you're feeling overwhelmed by the thought of blogging or starting something new, I never thought I'd have this much written by now! Keep at it and be consistent :)

Anyway... I wanted to put what I consider some of my best tips for writing notes all in one easy-to-find spot. Below are articles I've written here on QA Prep, as well as some other gems I've written for other people's sites. 

See what applies to you and check out the related article. Notice something you'd like to work on at some point in the future? Schedule it in your calendar now and bookmark this page so you can follow up when you have time to focus

Reviewing and improving your notes is an ongoing process. Don't feel like you have to do it all at once or learn everything right away. But if you don't schedule it and make that a priority, it's likely one of those things that will fall by the wayside. So take 30 seconds to schedule that time right now.

Let's dive in...

Questions to ask yourself when writing notes

It's always nice to have some guidance when sitting down to write notes. In this article I outline four questions you can post somewhere to ask yourself before writing notes. This helps to put you in the right mindset and keep the content something you can be proud of. 

Consider who may read your notes

There are actually many people who could potentially read your client's case notes. In this article I review the three people who are most likely to do so and how to consider what each may be looking for. 

Create your own notes template with check boxes

A lot of people ask me about creating check boxes for the notes in order to save time. In this article I outline a sure-fire process for doing this in a way that will still capture the individualized needs of your clients, as well as your unique ways of providing therapy.

Choose a notes template that works for you

Although I talk about some common notes templates in my free Private Practice Paperwork Crash Crash, this article gives you a quick read with similar information. I review four common notes templates and how they may apply to your counseling practice. 

Figure out how long your notes need to be

In this article I give you an example of both a short and long note and we evaluate what type of information we can remove in order to make things more efficient. This article is especially helpful if you feel like you write too much in your notes and want to cut things down.

Review your notes to see how you're doing

In this recent article I share some strategies for how to review your documentation. This is something I think is very helpful when you're feeling stuck with a client, as well as when you're ending treatment or writing summary letters. 

Write notes that make insurance companies happy

Notes don't necessarily need to be very different if you contract with insurance panels, but there are things you consistently need to think about with your documentation. In this article I outline the most important things to focus on if you think an insurance company may want to see your notes some day.

Identify ways to save time on notes

Most therapists are looking for ways to save time when writing notes. While I do encourage you to make documentation a meaningful part of the clinical process, efficiency is always a great thing! In this article I give you a variety of strategies for saving time on notes... and you can try out most of them right away.

Catch up on notes if you've gotten behind

It's a horrible feeling to get behind in your notes. Overwhelm takes over and it can be very difficult to find a way to catch up. In this article I share a five step process for catching up on notes, no matter how far behind you are!

There you have it! A comprehensive list of how to improve your notes and think about them a little differently. If you'd like more help with notes and documentation in general, you can check out my online workshop The Counselor's Guide to Writing Notes. I love seeing how people's fear of documentation shifts after they can see some examples. 

You can also check out my ebook, Workflow Therapy: Time Management and Simple Systems for Counselors. It's a compilation of my best tips and blogs on improving your efficiency and managing all the paperwork related items in your practice.

So whether or not I see you online or in person, happy writing. 

A Therapist's #1 Secret Productivity Killer

I talk with a lot of therapists who have trouble keeping up with notes. Yet, when we actually sit down to write notes together it only takes about five minutes to write one note (on average). 

Even if you see 20 clients a week, that's only an hour and 40 minutes every week to keep up with notes. If we assume a 40 hour work week, that still leaves more than 18 hours each week for all the extra administrative stuff you do (answering phone calls, marketing, billing, networking, etc.). This makes paperwork, and particularly notes, seem like a really small portion of the weekly workload, right? Especially when we consider how important your notes are for your business. 

So if it's not the time it takes to write notes themselves that's causing the problem, what is?

I've seen one problem come up over and over again... Not ending your sessions on time

Yup, this one thing is so easy to do but it eats up hours worth of productivity. Don't believe me? Let me count the ways, my friend...

Ending sessions late eats into the time you need to care for yourself. When you have clients scheduled back to back and you're not able to take some time to center yourself in between you feel more exhausted at the end of your day. It's go, go, go until the last client leaves. By the end of a day like that, the last thing you want to do is stay in your office and finish notes before heading home.

Even more practically, you may simply be hungry or tired and need to head home because it's dinner time, bedtime, take the kids to swimming lessons time, etc. 

One solution to this problem? Schedule yourself a 30 minute break in the middle of back to back sessions. Decide how best to use this time, whether it's for a walk around the block, taking a nap, grabbing a bite to eat or even catching up on a few notes. 

Now let me say that I do think it's okay to write your notes the next day. If I see clients until 8pm at night, that's what I'm doing! But the moment we put off that task we increase the likelihood that it will get pushed back even further (woops, forgot about that appointment tomorrow morning and then the kid's school thing!) and also that it will be of poorer quality whenever it does get done.

And guess what? It takes longer to write notes when you have to try and recall what actually happened in the session. I know I'm not the only one who has sat in front of a computer screen trying to remember what in the heck was that big thing I talked about in my session at 4pm two days ago. Now, a task that could take five minutes is taking fifteen minutes. And there are 10 more notes to do. 

Ending sessions late also eats into time you could spend on small tasks. One good thing about all of us being on our phones all the time is that you can actually be productive while doing things like waiting in line or sitting in the waiting room at a doctor's office.

Let's say you feel great in between sessions and don't really feel the need to center yourself, go to the bathroom or grab a quick snack. If you see 4 clients in a row and do 50 minute sessions, that's 30 minutes in between you can use to call someone back, confirm an appointment, briefly answer an email... Or even write a progress note!

By contrast, those extra 5-10 minutes you're providing your clients by going over in session aren't likely making a huge overall impact. Of course, there are always exceptions and the occasional session will go over but when this becomes a regular practice, it really takes up your time.

My whole point with using the phrase "meaningful documentation" over and over again is that your paperwork needs to suit your (and ultimately, your client's) needs. Same with your policies and procedures.

If you know you won't be ending sessions on time and don't want the stress, then own it. Plan around it. Use the 30 minute break strategy above. Schedule chunks of time to write your notes when you won't feel stressed about other things. Do what works for you to get the work done well. 

And if you feel like a little help with the technical part of writing is what you need to save yourself some time, check out my free Private Practice Paperwork Crash Course. In that course, I share strategies for simplifying your documentation and identifying templates that work best for you... another great time-saver. 

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors. 

Paper v. Electronic Records: The good, the bad and everything in between

Probably one of the biggest decisions therapists have to make about their practice these days is whether or not to go with electronic records (i.e. EHR). As with anything, there are benefits and drawbacks to this choice. Since I've had a lot of experience with launching electronic health record systems and evaluating workflows I thought I'd lay out all the pros and cons right here so you can make an informed decision about what's right for your practice. Let's dive in...

Paper Records

Pros:

The biggest pro to using paper is that you can start with it practically for free. Create or purchase a paperwork packet, buy some paper and a few file folders and you're set to go. Very little ongoing cost... although you do need to ensure you have a cabinet to lock all files. 

Another pro to using paper is that you can customize and change your forms at will, without worrying about requirements or limitations of an EHR. You can include a logo/branding to make them look nice and delete or add as many sections as you like. 

The third pro with paper is that some people really do have more of a connection with writing something. Also, if you do a lot of worksheets, artwork, etc. with clients in session it is very easy to throw those papers in a file, rather than scanning and uploading everything you want in the client record

Lastly, most people are familiar with paper. It is easy to set up and you don't have to learn anything new to get started. 

Cons: 

The biggest con with paper records is simply that you have to physically store them for so long! Most of us keep records for seven years (or longer, if you see children/teens) and it's really difficult to tell whether or not you plan to move at all in the next seven years. This can also make things difficult to track after multiple moves.

Related to storage is the fact that things can get lost. With paper records, you're really putting all your eggs in one basket and it's very easy to lose things once you start keeping multiple files. 

Another harsh reality is that files can be destroyed or stolen. I know people whose offices have flooded from a leaky sink not caught over the weekend, people whose offices completely burned down in a fire and people whose computer and other equipment was stolen. These things really do happen and it's unfortunate to lose so much information so easily. 

Lastly, many people simply write much more slowly than they type. Using paper records can be more time-consuming than using a computer to complete paperwork. This applies to both your clients as well as yourself and any employees/associates. In some ways, sharing documents can be easier with paper but it can also be more difficult if you need to fax or scan things that would've otherwise already been uploaded electronically. 

The In Between

So... what if you want to type your notes on a computer, but not use a cloud-based system? Perhaps this seems like the easiest solution. The main benefits here are that you likely already have a computer for work, you won't have to lug around a bunch of files or have an ugly cabinet in your office, and you also won't have to pay for a monthly subscription to keep records. 

However, most of the cons with paper still apply here. Your computer is probably the most likely item to ever be stolen and with this method you're likely putting all your eggs in that one basket. So, if anything happens to your computer (and even us Mac users have heard horror stories of people losing everything based on a glitch or a misplaced cup of coffee), well, you're screwed.

Electronic Records

Before we go over any pros and cons with electronic records, it's important to note that while there are some great EHR's out there, no system is perfect and no system will have everything set up exactly the way you want. With that in mind, let's look at what the general pros and cons include...

Pros:

Probably the biggest pro of using an EHR for your private practice is that all your records are easily housed in one place. You simply log in and voila, everything you need! If you have internet access, then you can access your full client records from any location. Many EHR systems even have apps so you can write a quick note from your phone.

Another huge pro is that having your records in an EHR will likely provide the safest records storage available. While we're all concerned about hackers, and that is certainly something to keep in mind, a good EHR will provide excellent security. This security will be far beyond what you could create for yourself, either using paper or keeping notes housed on your computer.

And because you have easy access to safe storage, many EHR's will safely store credit card numbers for your clients. Roy Huggins has a great article (click here to read) discussing the reasons you probably don't want to collect your client's credit card numbers yourself. Having them write their credit card information on a form you keep is very unsecure. But if you use an EHR that has this set up through a merchant account, they are ensuring the security is up to date and you can ensure you'll be paid. 

If you contract with insurance companies, an EHR can save you tons of time because they typically include billing. While that doesn't mean they're going to call to check eligibility or follow up on rejected claims, they will often submit your claims electronically as soon as you enter the necessary data. Again, everything you need in one place. And if you provide clients with a super bill, most EHR's will print out a nice one for your clients based on the sessions you've entered.

Lastly, another benefit to using an EHR is that many offer client portals. This means your clients can log in to complete and upload paperwork before appointments, and even interact with you securely. This can save worry about email communication or clients forgetting to bring in needed paperwork.

Cons:

The most obvious con with using an EHR is the cost. While most are actually providing an exceptional service for the price, it can still be a stretch if you're just starting out and only have a few clients. This is where it's really important to think through all your expenses and also, your long-term goals. Using an EHR is probably one of the best investments you can make for a therapy practice... but if the money's not there, then it's just not there.

Another con is that despite your best efforts and our tech society, there is still a lot of paper going around. This means you are likely to end up scanning documents every once in a while. For some, this may be just a couple pages a year but for others (and depending on your particular EHR set up) it could mean LOTS of scanning. Consider your clientele- do you tend to work with people who often have reports or require lots of communication with other providers? If so, you'll want to consider a more robust system that allows clients to upload documents. Also, if you have an assistant, this may not be such a big deal.

Lastly, another con with EHR's is that some offer limited ability to customize your documentation. You know this is a big one for me because I believe that you should personalize your paperwork to your client's needs as much as possible. Some EHR's do allow you to create your own templates, some don't, and some charge extra for this feature. This is where shopping around and trying things out ahead of time is crucial. The last thing you want is to get everything set up and then realize the notes or treatment plans are a total pain to work with!

Some Cons to All Methods

One mistake I've seen over and over applies to all records, paper or electronic. That's putting something in the wrong client file. I've seen people physically put the wrong note, release form, etc. in a paper file and I've also seen people accidentally type a note in the wrong client's file within an EHR. Some people have never made this mistake, some people have done it multiple times. Obviously, the key here is to make sure you're taking time to be mindful of what you're doing when writing notes. 

An EHR can save you lots of time and headache, but it can't think for you. So regardless of which method you use, make sure that documentation isn't an afterthought. Instead, let's make it a meaningful part of your practice. 

If you're looking for tips on how to personalize your mental health paperwork, check out my free Private Practice Paperwork Crash Course, where I walk you through different ways of writing notes and treatment plans, as well as what to focus on during intake. 

Feeling Stuck With a Client? 3 Ways Your Documentation Can Save the Day

We've all been there. That moment in session where you realize you've had this same discussion with your client before and it ended up nowhere. That moment you see a family or couple bringing up exactly what they seemed to have already worked through. That moment you find yourself searching in your mental toolbox but come up empty-handed.

That moment where you have nothing to say and are having difficulty finding hope in the situation yourself.

While these situations are uncomfortable and often disconcerting, they hold huge potential for growth and change. But as with most obstacles that seem like a 12 foot wall, these situations usually require a different strategy in order to overcome.

What's the awesome strategy I have for you in these difficult clinical situations?

Do a review of your client's file.

Before you stop reading, let me explain!

Usually when you come across these clinical scenarios it's after you've done some work with your client. These situations don't typically pop up in week one or two because you're getting to know your clients, they're motivated to change and your plethora of clinical tools are at your disposal. 

But for those times when it's months later and your toolbox hasn't proved as helpful as it normally is, this little trick can be a game changer. 

Because now you are looking at your client with different, more experienced eyes. 

Have you ever had a situation happen where things weren't making sense and then someone offered you some insight... and when you looked back on things you realized all the signs were there early on but you just couldn't see them yet? That's what your documentation can do for you, offer that critical insight.

1. Go back to the very beginning.

Look at your client's intake paperwork. How did they present when they first came in? What did they identify as their main problem? Did they identify goals? 

Also notice if anything seems missing. Perhaps their original paperwork denied substance abuse but you discovered otherwise later on. Perhaps they noted a happy family situation but have talked about nothing but being unhappy in their marriage for the last three months.

Is there anything that pops out at you as unusual or noteworthy now that you know client more? If so, perhaps there is something you can bring up in your next session to change the cycle of repetition or feeling stuck.

2. Evaluate your treatment plan.

Do you have a treatment plan with your client? If not, this is a great time to start one! Talk about their goals, ways in which they feel they have progressed and what they would like to see happen in the future. 

And whether or not you already have a treatment plan, this is a great time to ask about how counseling is going. Do your clients feel things are going well? Does it feel like anything is missing?

If you've already got a treatment plan going, bring that out in session to check in. Are you both on track? Does this plan still make sense? Are there things either of you could be doing differently to help achieve these goals?

Make it a conversation but don't be scared to actually have a treatment plan written out and share it with your clients. This is where the paperwork can be a great catalyst for insight.

3. Review your notes from day one.

Lastly, start with the very first note in your client's file and read through chronologically. What stands out to you? What progress has been made? 

Any topics you find coming up again and again? What were the plans related to those topics? Was there follow through on any homework or plans?

Try to be as open in this process as possible. There may be something that jumps out at you right away that you've never noticed before. There may also be behavior you realize you're enabling or something clinical you realize you've missed and should address.

Really focus on conceptualizing your client's case and how to best meet their needs. This will certainly bring up questions or ideas you can address with them in the next session.

"But Maelisa, I did this and realize my notes are so minimal they don't really give me much information."

That's okay! First, take that as valuable information and adjust your note writing a bit (from now on) to include a tad more detail. Second, ask your client to help you fill in any gaps! Not literally on paper, but start your next session with an overview.

Ask your client about any sessions they found particularly meaningful or any times they felt resistant to things you discussed. Perhaps you can create a "best of" list or a "most helpful" and "least helpful" list. This is a non-threatening way to talk openly about what works and what doesn't and to review treatment overall.

If you're feeling stuck with a client and try this technique out, let us know in the comments below! And if you want more help on using your documentation as a clinical tool, check out my upcoming workshops or try using my paperwork packet. Sometimes it takes a little trial and error so be kind to yourself but keep at it. Your clients will thank you.