Many therapists struggle with the lack of direction given regarding client files. How do you organize a file for private practice? What needs to be in the file, other than notes? Are there any standards?!
While there are some standards regarding what should be in a file, there aren’t many standards regarding organization. Most large agencies do have similar ways of standardizing files and I recommend following that type of mindset.
Follow the timeline of their story with you. Basic organization usually follows a chronological story and has a clear beginning, middle and end. Think about what happens when a client contacts you, their first session, and things moving forward until treatment ends. Easy, right?!
Now, this mostly applies to those of you who keep paper files since electronic health records organize things a certain way and you typically have little flexibility. But most of them probably also follow this chronological timeline.
So, let’s dig into the specifics… I’ve got various sections of a client file listed below, all in the order I recommend you include them:
Intake information- this includes demographics, contact information, and any type of client assessment form or questionnaires you complete during the intake/assessment phase.
All signed documents- this includes informed consent, social media policy, court policy, credit card authorizations, releases of information, etc. Anything your client signs as acknowledgement or agreement should be included in their file.
Treatment plan- this may be a quick note or a more formalized treatment plan template that you use. Regardless, we ethically need to have some sort of treatment plan. I recommend keeping it here as it serves the purpose of connecting what is originally identified as the client need and how that’s addressed in session moving forward.
Notes in chronological order- these are all your interactions with your client. The largest chunk will be your regular client sessions, documenting no shows or cancellations as well. This also includes notes on texting, emails or other outside interaction. While I don’t think it’s necessary to print out or copy and paste every email or text, it is important to document interactions you have with your clients. Remember, you’re telling a complete story.
Reports or correspondence from other providers- you may or may not use this but if you receive info from other professionals, include that in a section near the end.
Other correspondence related to the client- this is sort of your catch all for things like letters or any other type of communication that may not be related to other professionals.
Insurance- if you work with insurance directly you’ll want to make sure you document any requests, correspondence or billing related matters.
Other- Artwork, letters, etc. Lastly, the true catch all for anything else you can think of! These may be exercises you complete during session. Some people choose to keep more sensitive projects (for example, a trauma narrative) separate from the main file in order to protect confidentiality. That is also an option.
So there you have it! A complete, organized client record.
What insights did you gain from this article? Anything you plan to adjust? Let us know so we can help one another out!
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.