Insurance Records Requests: Rules to Remember

Here’s a question I get all the time:

Can insurance companies request my therapy records?

Sometimes it’s asked a different way:

Do I have to submit therapy records (including progress notes) if an insurance company requests them?

>> This applies to anyone whose clients use insurance to pay for treatment, and that’s often what mixes people up. So for those of you who submit superbills, this post is still for you. Keep reading (or watch the video below).

The answer, in case you’re wondering, is YES.

If an insurance company is paying for counseling or therapy, they can absolutely request records. They can request the entire record if they want, they can request copies of notes, they can request a summary—it runs the gamut. They can ask for as much or as little as they want.

The pushback I hear from therapists is that it feels wrong, or it feels like an injustice, because we are worried about client confidentiality. That’s a valid concern!

However, what we as therapists need to address, is that it is part of our job to know a request for therapy records is a risk when clients use insurance to pay for counseling, and therefore it is our job to inform our clients of this risk.

So as soon as you contract with an insurance company, you need to make sure that your intake paperwork and everything you go over with clients includes this information:

  • Insurance companies can request therapy records

  • You can talk to the insurance company and give them basic updates

  • Insurance requires a mental health diagnosis for treatment to be covered

Then you need to make sure you’re covering that info with your clients in person.

Making the very real possibility of records being shared will often push clients to pay for therapy themselves rather than use insurance, because they realize they may not want their insurance company to have access to all that information.

It’s also important that you tell your clients that you are required by insurance to provide a mental health diagnosis, so they know they will have a mental health diagnosis on their record, and their insurance company will know that.

And I cannot emphasize enough how important it is to know that if you aren’t contracted with an insurance company, but your clients sometimes request their superbill to send over to their insurance company themselves, you still need to be having the conversation about potential limits to their confidentiality.

So unless you refuse insurance completely AND never provide superbills, I suggest you always cover the possibilities of insurance records requests with all of your clients to make sure you’re covered and the clients know the potential outcomes.

And this brings us back to what I mentioned before, that clients should know they’ll have a diagnosis on file. Insurance requires a diagnosis to establish medical necessity for treatment.

The key here is making sure your clients know they will have a mental health diagnosis on file AND it’s important that you consider what that mental health diagnosis is.

It is considered insurance FRAUD— illegal, unethical, something that could lose you your license—to give an inaccurate diagnosis.

What does accurate diagnosis mean?

It means that if a client has a “severe” diagnosis, that you don’t under-diagnose them. For instance, not wanting a client to deal with stigma of bipolar disorder, so diagnosing them with adjustment disorder instead. Read more in this blog about common diagnosis issues.

This also means that if a client doesn’t meet the criteria for diagnosis, insurance companies won’t pay for therapy, and it’s illegal to give them a diagnosis (like Adjustment Disorder) if they don’t fit the criteria. So you should have a note in your paperwork that clients who do not meet a diagnostic criteria likely can’t bill insurance.

If you’re still not sure you understand this, there is plenty more info to educate yourself! Check out my free crash course where we talk about insurance, as well as notes, intake paperwork and treatment planning.

Using Treatment Planners to Write Counseling Treatment Plans

Treatment Planners, they’re everywhere, right? Treatment and Notes planners are super popular and there are so many options available on Amazon, but are they helpful? Do you need one?

Today I’m going to review:

1. When treatment planners are helpful

2. When they’re not so helpful

3. What to look for in a planner
4. What to do if they aren’t the right choice for you

Watch the video below or keep reading!

First, when are treatment planners useful?

Generally treatment planners are useful when your client has a specific diagnosis, and you treat them according to that diagnosis.

Most treatment planners are based on diagnoses, so if you tend to give a diagnosis as part of therapy and rely heavily on it for your treatment plan, then it makes sense.

All the interventions and client responses in the planner are going to be based on a particular diagnosis. Plus, these treatment planners are ordered alphabetically by diagnosis, making them a good bet if this is how you work.

Which means that second

If your client doesn’t have a diagnosis, or you don’t give diagnoses, then a treatment planner probably won’t fit in well with your work.

We ALWAYS want the treatment plan to be serving us, not the other way around!

If a diagnosis isn’t guiding the focus of your treatment, treatment planners aren’t so helpful. This is the first thing to consider. Don’t buy something that’s going to make your work harder.

Leading us to third:

What should you look for if a treatment planner makes sense for you?

You want a treatment planner that is focused on the interventions you’re providing, the types of clients that you see, and that’s easy to look through.

Consider all these things when choosing a treatment planner:

  • How is the planner you’re considering ordered?

  • What therapy and treatment interventions are provided?

  • What are the therapy interventions based on and are they recent?

  • Does it include interventions that might be based on a particular modality you use (or don’t use)?

And finally, number four:

If treatment planners don’t fit with your practice, you might be feeling down right about now. I know the idea of a treatment planner is awesome. It sounds like the answer to our problems for creating a treatment plan, but often it is not.

But I have GREAT news!

I have a FREE treatment plan template that you can use (go ahead, have a little party) that also serves as a guide. If you have a treatment plan template it serves the same purpose as those treatment planners, directing what to include in treatment and how to talk to clients about it.

Join the Private Practice Paperwork Crash Course for a specific lesson on treatment planning and the free template you can start using with clients right away.

Group counseling notes: What you need to know

Are you a therapist who recently decided to start a group, or is even just considering it, and then thought, “Wait — How do I write the note?”

I’m here to give you the basics so you feel confident documenting those group therapy sessions.

The first thing to remember is that group notes really aren’t that different from individual therapy notes. Phew, right? So breathe deep and relax, because you can do this. The notes are pretty much the same and some parts are *exactly* the same, and that will help you save time.

The biggest difference in individual therapy notes from group therapy notes is that you need to document the individual interactions AND the group interactions. And the good news about THAT is: it’s pretty easy.

Step One:

Follow your normal progress notes template. Whichever one you use — DAP, SOAP, GIRP, PAIP, or your own format — and make sure you include all those components in how the individual client acted, how they interacted with the group, how the group reacted to and interacted with them, how they influenced the group, and how the group influenced them.

It sounds like a lot, but I promise, it really isn’t.

Step Two:

My biggest advice for therapists writing group notes is:

DON’T WRITE ANYTHING TWICE!

This means you can sort of “cheat” a little in group notes, and this is where you start saving time. How? Well as you work with the group you might provide an intervention for the whole group, and you definitely don’t need to write that five or ten times. Write it once, and then copy and paste into everyone’s individual note.

I heard that little sigh, even through the computer.

Yes, you do still need to write individual notes for each member, because they are each still individual clients and should have separate therapy records.

So you’ll have a portion of the note that deals with the whole group, interventions you provided, the things you did that apply to everyone, and another few sentences specific to that client.

Easy enough, right?

Use your template and take advantage of those little tricks to save yourself time: Copy and paste what you can, and then add the individual components highlighting how the group is different for each person.

That’s it. You’re done!

Are you doing group therapy? What tips and tricks do you use?

If you want more information on the notes templates listed above, or aren’t feeling confident with your individual notes yet, check out my FREE Private Practice Paperwork Crash Course.

For more in-depth help with writing progress notes, check out the Meaningful Documentation Academy, which is full of trainings on notes, treatment planning, time management, and more.

Documenting Text Messages and Emails

“Do I need to copy and paste all emails from clients into their file?”

“How do I document or save text messages with clients?”

These are concerns that usually come up for mental health therapists after they start seeing clients, and after they’ve reviewed policies and procedures with them. It’s okay though, even if your client starts texting you out of the blue and you had no policy around this, you have plenty of options for documenting this conversation… easily and simply.

Let’s review some tips for documenting text messages and emails with your counseling clients:

Think of texts and emails like voicemail.

Remember when all you did was talk on the phone? Life was so much simpler then… in some ways.

The problem is that we often over-complicate things when they are new, and texting or emailing with clients is still relatively new in the world of mental health.

But when you think about it, texts and emails are commonly replacing communication that would have happened over the phone 20 years ago… so a good question to ask yourself is, “What would I do if this were a voicemail?”

You’d likely write a brief note about the interaction. For example, you might write something like:

“Client left voicemail cancelling session due to being sick. I called her back and she will attend next session on xx/yy/zz.”

That’s it! Easy!!

Same thing with a text or email communicating the same type of information. Simply write a brief note in the file so you remember what happened and it’s documented for good.

Summarize, summarize, summarize

I really don’t believe it’s necessary to copy and paste most emails or text messages with clients. The key is to make sure you do have the communication documented in some way, and the easiest way to do this is to summarize in a brief note, like the example above.

Don’t overwhelm yourself!

Tracking and copying all this information may be unrealistic but it doesn’t mean you’re being unethical or not able to document the important aspect of the communication.

And if you prefer to have ALL the back and forth communication with your clients, there are actually some cool apps available that will save this information for you. They offer a secure way to text with clients and the ability to print out or review any text messages.

The added benefit of email and text communication with your therapy clients is that, when needed, you actually can copy and paste the entire communication.

While I don’t recommend doing this every time, it can be very helpful when ethical dilemmas arise or when there is confusion about the communication.

So, in my opinion, these types of communication can actually be more useful than voicemails! It is unlikely you’d want to save a full voicemail from a client, but copying and pasting a long email into your EHR takes about 30 seconds… and gives you a secure way to save potentially important communication.

Let us know in the comments below:

Do you save all your emails or text messages with clients? Do you use an app to communicate with clients and save all the data?

Remember, there’s no right or wrong answer here and we can all help one another by sharing.

Writing Court Letters in Private Practice

There are few things that stress out therapists as much as dealing with a subpoena or a request for records. Most of us prefer to avoid anything court-related at all costs.

However, many counselors unknowingly get involved with court cases through one simple step: Writing a letter that is used in a court case.

While a letter is often preferable to releasing all the psychotherapy records, it’s important to remember that letters can also have significance and we should be careful about what we write. We also need to make sure we review the potential consequences of letters with our clients.

You might be thinking, “What can be so harmful about writing a simple letter?”

Well, it is not so much the letter itself, but the potential for blurring lines of competence that can get therapists into trouble.

Let’s review a common scenario for writing a court letter…


We'll call our imaginary therapist in this scenario "Mary Muggle, LMFT." Mary has been seeing children and adolescents in a private practice setting for about 10 years and has been licensed for about 12 years.

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. During extensive research into common board violations among various practitioners, I found very few examples of newer therapists making a violation. 

Mary begins seeing a 10-year-old boy we'll call Dudley. Dudley's parents are going through a divorce and over the last two months his grades have been dropping and he started getting in fights at school. His mother brings him to treatment and explains that Dudley's father travels frequently for work and is aware that Dudley will be getting counseling but doesn't want to be involved.

Mary asks for custody paperwork and Dudley's mother brings in a form that isn't very clear but it appears that the parents have equal custody for now. Mary files this with her records and begins seeing Dudley for weekly therapy. She does leave a voicemail for Dudley's father to see if he can come in for an appointment but she never hears back.

During his sessions Dudley often reports missing his father because he sees him very irregularly now that his parents are no longer living together. He reports visits with his father being sporadic and including lots of take-out or junk food and very little discipline or structure. His father also does not seem to approve of Dudley being in therapy and says things like, "Fighting isn't a problem. Not sticking up for yourself is a problem. Don't let them turn you into a pansy."

After about three months of weekly sessions Dudley has made some improvement in school and seems to enjoy his weekly sessions but admits to Mary that he feels embarrassed to talk about them with his father.

It is around this time that Dudley's mother asks Mary to write a letter for an upcoming court date.

She is worried that Dudley's father will ask for therapy to be discontinued. She also confides that she is concerned his father will request more time with Dudley now that he is done with the work project that required so much travel. 

Mary writes a letter summarizing Dudley's reason for referral, his goals and progress to date, as well as Dudley’s concerns about his father not supporting the therapy process. She highlights in the letter that this can be detrimental to therapeutic rapport, Dudley's ongoing progress in school, and she reports that Dudley's father has been uninvolved and may be a negative influence. She also recommends Dudley's mother remain the primary caregiver.


Writing a letter about Dudley's treatment is perfectly acceptable, but Mary makes two critical mistakes in this scenario:

  1. She provides an opinion about Dudley's father without ever talking to Dudley's father.

  2. She provides a recommendation related to custody without being appointed (or even trained) to do so.

These mistakes are critical errors because Mary is practicing outside her scope of practice and has a potentially harmful dual relationship.

Let’s dig into each of these issues…

The Ethics of Dual Relationships and Scope of Practice

As mental health professionals, we often see into the very vulnerable parts of individuals and families. We also form a connection with our clients. We like to use the term “therapeutic rapport” to sound more academic but it is often a basic, human connection we have with our clients.

This connection is important for counseling to provide a healing environment where clients can be vulnerable. However, this connection impairs our ability to be objective.

That is why, for example, it is usually unethical for me as a psychologist to do psychological testing with someone who is also a therapy client. Or to test someone whom I already know well.

No matter how objective psychological tests are, my interpretation or evaluation report is very likely to be influenced by my prior knowledge of the person’s abilities, history, etc.

Likewise, our relationship with our clients can impair our ability to objectively look at other situations, such as custody agreements. This applies when your client is the child, as well as when your client is one of the parents.

Custody situations are often very emotionally charged for all involved and this makes objectivity that much harder.

So it is generally considered unethical to provide an opinion about custody unless you are specifically trained in providing such assessments (which often have very specific legal guidelines and ramifications) and have no prior relationship with members of the family involved.

Are there exceptions to these guidelines? Always!

For example, if you live in a rural area and there are very few providers, you might be the only person available to provide such an assessment, despite some type of prior relationship with the family involved.

This is where we must consult our ethical guidelines, consult with colleagues who can offer guidance, and disclose all the potential things that might be impacting our objectivity.

So what do we do about writing court letters?

Keep writing them!

(Or don’t… more on that in a minute)

Yes, keep writing them but always keep in mind that letters can have a significant impact and…

It is not your role as the therapist to make legal determinations for your clients.

>> Should your client be excused from work because of the significant stress it is causing? Your role is to assist the client through this process and potentially, provide a letter explaining their current symptoms and stressors.

>> Should your client receive social security disability because of their diagnosis? Your role is (usually) to report the symptoms, history of these symptoms, impact of the diagnosis, and the prognosis based on your ongoing professional assessment.

>> Should your client who loves his children have custody of them because their mother (his ex-wife) is an alcoholic and currently in jail? Your role is to simply report your client’s progress in treatment, regardless of the circumstances.

Most counselors are well-meaning and genuinely think the recommendations they include in letters will benefit their clients, and the others involved.

We became mental health professionals because we want to help people! And it often seems unfair when we can’t help our clients the way we want.

However, you can help your clients when they are experiencing any of the above scenarios.

Here are some general guidelines for writing letters that might be requested by an attorney, sent to an evaluator, or used to determine a client’s role or benefits in some way:

  • Discuss with your client the limitations and potential ramifications of writing such a letter and that you cannot guarantee any type of result, positive or negative.

  • Stick to the facts. All of your statements should be backed by data (whether that’s your own clinical assessment, reports by others, observation, etc.).

  • Report on what is observable and provide examples or quotes, if needed. Keep in mind that your client’s statements about the situation or anything you have observed might be relevant here.

  • Keep your opinions about anyone or anything that is not your client out of the letter. For example, Mary could certainly write that Dudley’s father has been unresponsive to her attempts to reach out and therefore uninvolved in treatment. Those are facts based on her experience, not an opinion.

  • Keep it simple. Stick with symptoms and/or reason for referral, progress to date, and perhaps, prognosis for treatment.

  • Don’t be afraid to say no or to charge for your time. Writing letters is stressful and it does take time, but it’s also not required, unless you have a subpoena or some other type of court order. You have every right to say no or to charge a reasonable fee for your time. Just make sure this is outlined in your policies!

Keep in mind these guidelines are generalized and you must always consult your own state laws and professional ethics!

Using these guidelines should help you stay ethical, provide excellent care for your clients, and create a less stressful experience for you as the treating therapist.

How do you handle requests for letters from clients? Let us know in the comments below!

Process Notes: What You MUST Know

Maybe you’ve heard some of these terms and are confused about how they are different (or the same!)…

  • Process notes

  • Progress notes

  • Psychotherapy notes

  • Case notes

  • Clinical notes

What do all these terms mean?!

Fear not, amazing therapist, I am clearing this up in the video below!

And in case you’re not into videos, here’s a snap shot of what I cover:

  1. “Psychotherapy notes” and “process notes” are the same thing, we all just tend to use different terms. The term “psychotherapy notes” was created specifically for HIPAA so this impacts how we use this term.

  2. Process notes are totally optional! Yup, there is no requirement to write them, so it’s totally up to you.

  3. Process notes don’t even have to be legible. You can draw, use shorthand and abbreviations. In short, you can do what you want since they are just for you.

But most importantly, process notes are NOT a place to hide important clinical information that may be needed for treatment.

Your progress notes should always document treatment and should be able to stand alone to tell the story of your client’s journey in therapy.

Now, let us know! Do you use process notes? Why or why not?

Credit Card Fees and Private Practice: Can I Pass the Fee to My Client?

Credit cards are pretty standard practice in the world of mental health these days. And, in my opinion, that’s a good thing.

Credit cards mean it’s easier for clients to pay for services, you can be assured that you’ll be paid, and clients can often use Flexible Spending Accounts to save money and pay for therapy.

However, credit card processing is NOT free so someone has to pay for these companies to create massive firewalls and protect our client’s personal data… but who pays?

In this video I explain you shouldn’t pass the fee on to your clients… but I also explain how to do this without losing money yourself.

Because yes, having a modern therapy practice does cost a bit more these days, but it’s totally worth it.

I mentioned IvyPay in the video and yes, if you click on the link below you’ll get $1,000 free in initial credit card fees! Yay, thanks, IvyPay!

Click here to check it out.

You can learn more about all the things to consider with credit cards by checking out this blog post on Credit Cards: Your Questions Answered.

Let us know in the comments below! Do you factor in credit card fees when creating your own fee for counseling services?

What is Medical Necessity?

Medical necessity is a term that is based on the medical model of treatment but is also applied to mental health treatment. Sometimes that can be confusing for those of us who are counselors, therapists, social workers and psychologists!

In this video I explain:

  • The three main components of medical necessity

  • Why insurance companies use medical necessity for mental health

  • Where you want to highlight medical necessity in your documentation

Let us know what you think in the comments below:

Are there other strategies you use to talk with insurance companies about medical necessity and psychotherapy?

Does this seem to cover what is needed for your progress notes and insurance?

Quick Clinical Case Notes (Collaborative Documentation Q&A)

Recently I've been getting a lot of questions about a somewhat controversial topic- collaborative documentation.  While I don't think everyone should use this strategy, I definitely think it's worth considering. 

Collaborative documentation (sometimes called concurrent documentation) can actually look very different for different therapists!

In this video I review four ways you can incorporate this strategy in your counseling practice right now:

  • Writing notes with clients in session

  • Writing part of the note with clients during session

  • Sharing notes with clients after they are written

  • Having clients complete intake paperwork before the initial session

I also go through some of the benefits and potential drawbacks of this technique:

  • Less time writing notes (the most obvious benefit!)

  • Increased communication and connection with your clients

  • Reduction of errors in documentation

  • Better engagement of "resistant" clients

If you’d like to submit a question for me to answer on a future YouTube Live Q&A, then click here.

>> Subscribe to my YouTube channel and click the bell for notifications so you don’t miss the next Live Q&A! 

I'm on every Monday at 12pm Pacific Time.

If you’re still looking for help with your documentation, click here to check out the FREE Private Practice Paperwork Crash Course

Do Therapists Really Get Disciplined for Failing to Take Notes?

One of the biggest concerns I hear from counselors about their documentation is whether or not their notes will be read by someone else. Usually they are most concerned by a potential court case Their concern is that the notes will somehow harm their client in this case.

Click here to read about whether or not I think limiting your note content can help you or your clients with court cases.

Secondly, the concern is about others reading their notes and that they will be deemed an incompetent or negligent clinician when the notes are revealed. 

Why are so many therapists worried about their notes somehow revealing poor practices? 

I find that the lack of clarity about what to write in therapy notes contributes to a LOT of worry. That worry builds when counselors seek out information about how to write progress notes and they find a myriad of conflicting information from seemingly reliable sources. 

The worry grows exponentially when that same counselor falls behind in their notes and needs to catch up on paperwork

Then you add to that a horror story of another counselor being put on probation or losing a contract due to poor note writing and this becomes a real concern!

But is it true that psychotherapists get disciplined for poor record keeping? Does this really happen?

Yes!

I find this commonly happens when some other catalyst creates a client complaint or Board investigation.

When the Board begins to investigate and requests records, they often find two additional problems (other than the original complaint):

  1. The clinician failed to obtain proper informed consent.

  2. The clinician failed to maintain adequate records.

Keep in mind that these common scenarios are regardless of whether or not the therapist is actually found to be at fault regarding the original complaint. 

So, let's dive in to each of these two scenarios and see how to avoid these common issues...

The clinician failed to obtain proper informed consent.

1) This often occurs when therapists are providing services to children and adolescents. The therapist may fail to inform the parents when it is required or may fail to obtain consent from the correct party (or both parties, if required). Similarly, this can also happen when a dependent adult is being treated.

2) I've also seen cases of this when a psychologist failed to obtain proper consent for psychological testing or did not adequately document reviewing the differences between a testing and a therapeutic counseling relationship. 

3) There are also scenarios where the therapist does not actually review the informed consent process at the beginning of therapy. Instead, they simply make sure forms are signed and don't review any policies or procedures, potential limits to confidentiality, or describe the therapeutic process.

When counselors are too lax about the intake process and jump right in to the therapy process they set themselves and their clients up for a potential disaster and significant harm to therapeutic rapport.   

4) Lastly, the counselor may simply fail to document that they obtained consent for treatment. I always recommend you document in an intake note that you reviewed necessary policies, potential limits to confidentiality and obtained consent for treatment.

The clinician failed to maintain adequate records.

1) One common problem here is that the therapist simply has incomplete records. They may be missing case notes, informed consent documents or other necessary paperwork, such as releases of information.

2) Another common problem is that the therapist has case notes but no other supporting documentation, such as a treatment plan or intake paperwork.

3) Lastly, the issue might be around quality of documentation. For example, the counselor only includes such brief information in their case notes that the Board cannot adequately determine if their actions are justified. Or the counselor may fail to document things like important phone calls or missed appointments that corroborate their side of the story. 

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. I found very few examples of newer therapists being disciplined for these concerns. 

What can you do to avoid these potential problems?

Two ongoing things are critical for every licensed psychotherapist in every discipline, state and country:

So, just reading this blog post you are already on the right track! You're making ongoing learning a priority for your career. 

And despite the fact that you may hear different opinions about documentation practices, regularly discussing these practices with other clinicians, along with educating yourself on best practices, will help you gain the critical thinking needed to decide for yourself what you will do in your practice. 

If you're looking for a community of other therapists with whom you can consult, as well as a place to obtain continuing education credits and learn about individualized documentation techniques, then click here check out the Meaningful Documentation Academy

The Academy incorporates community and education to make sure you are prepared and confident about all things documentation.

Productivity Hack for Writing Case Notes

I've got a quick tip for you that can dramatically improve your productivity when writing case notes and catching up on paperwork!

In this video I share with you the Pomodoro Technique, a popular time management strategy for getting tasks done.

The key to the Pomodoro Technique is taking breaks! Do NOT skip this part and when you're trying it out make sure you stick to the schedule. 

This is one of the strategies we use for the weekly Get Notes Done Hour in the Meaningful Documentation Academy, as well as our quarterly Get Notes Done Days... and people are really liking it!

Let me know how this strategy works for you in the comments below.

Assessment Dilemmas and FAQ's

assessment dilemmas.jpg

Everyone does intake assessment a little differently. On one end of the spectrum we have clinicians who simply have clients sign a one page consent form and then dive into the client's ongoing struggles and then transition to a traditional therapy session. Not much discussion about policies, not much paperwork, and history on an as needed basis ongoing.

On the other end of the spectrum we have clinicians who use a structured intake document to gather biopsychosocial data and may use up to three sessions to complete this document and formulate a diagnosis. Lots of discussion about history, lots of paperwork and notes, and allowing plenty of time to evaluate symptoms as they develop.

And then a lot of us (myself included) are somewhere in the middle. 

Since you may be curious about my personal take on this, I'll share my own process here. But do please note that I often recommend people do things differently, based on their own practice and experience. It just depends on what works best for you

My assessment process

Personally, I use a structured form and ask clients to complete this form ahead of time. I do this for a few reasons:

  1. I get to read the client's description of their problem, strengths, etc. in their own words. I can then use this to build rapport more easily and it often gives me a better understanding of what's going on, even if we've already had a detailed consultation over the phone.
  2. It saves me time. Just as important as the above, I don't have a huge form to complete during or after the session! 
  3. It helps my memory. Since the form is mostly (if not all) completed I can focus on asking follow up questions, diving deeper into relevant topics or asking about things that may have been skipped. I don't have to worry about doing the whole thing or trying to write down important quotes or information in the moment.

I typically look over the form before meeting with the client and jot down a few notes to myself about further questions or things to explore. However, when the client arrives I first make sure they understood all the paperwork (which they typically sign ahead of time, as well) and review the relevant important things like limits to confidentiality. Then I ask them to tell me more about why they're seeking help at this time and go from there.

So, while I do start out fairly structured, I let things unfold once we have the formalities out of the way. Sometimes the topics we cover are many and sometimes we are much more focused. It really depends on the client. 

However, near the end of the first session, I do make sure to give them an idea about how I think I can help, how I work, and sometimes I will also give a potential timeframe. For EAP or insurance, this timeframe can be very important because it means we're already discussing how to best use our time together since it may be limited. I've found that clients really appreciate this open and honest communication and it helps them become more engaged. 

We will then review what we think our goals for working together are and move on from there. These things often change and that's okay, but after the first session I like for us both to have an idea about how we'll be working together and for the client to be thinking about how they can evaluate me and whether or not I'm the best fit to help them. 

So, that's my structured and unstructured assessment process! I get a formal intake document and a treatment planning discussion in there, but focus primarily on connecting with the client and learning more about their needs and goals.

Your FAQ's about assessment

So what is "recommended" or "best practice?" What works best for insurance? How much time do you need to spend on an assessment? Well, I get a lot of more specific questions like these and below I'm going to address them!

Continuing our FAQ series, below are questions from the QA Prep community about issues related to intake assessment. I do my best to answer these questions based upon my own experience but welcome your feedback below in the comments. Share your tips with us, as well!

"Because assessment is an ongoing process, how in depth are you when completing an assessment at the initial session?"

As I mentioned in my own process above, I am in-depth but only as it relates to the client's current needs. For example, if I am working with someone who is experiencing work stress and not being fulfilled at work, I often do not go into childhood history or past trauma. However, if the client is struggling with managing expectations at home and work because of a difficult relationship with their parents who also provide childcare, that may be a more relevant topic that we dive into.

Of course, we will always gather more information and continue assessing clients ongoing. That is a given.

However, the purpose of an initial assessment is really to make sure you have a clear understanding of the client's need so that you can adequately plan for their treatment. 

That means you want to have answers related to things like:

  • Whether or not you are within your training and expertise to treat this client's need/problem
  • What additional resources or collaboration may be needed (e.g. physician, psychiatrist, couples counselor, sobriety services, etc.)
  • For insurance, whether or not the client meets medical necessity criteria

So, I would say that I am in-depth regarding the "presenting problem" but not necessarily other topics. However, if you bill to insurance companies you may still need to ask other questions and this may limit your ability to be as in-depth, or may simply extend the assessment timeframe. I'll address these specific things below...

"Are there specific questions that must be in the intake assessment? How long should the assessment be?"

Yes, there are a few things I recommend every clinician review as soon as possible with clients:

  • Reason for seeking treatment
  • Goals for working together
  • Strengths and hobbies
  • Current living situation
  • Potential or past feelings/thoughts of suicidality or homicidality
  • Criminal history
  • Substance abuse history

The reason I listed the above things is that I believe these are all things that can become very important information very quickly, depending on the client's answer. For example, if you work in an office alone and sometimes work late at night you will want to know about any history of violent behavior from potential clients. Likewise, it is important to assess suicidality as soon as possible so that you can address this if it is a concern. 

I also think it is important to quickly assess the reason the client is seeking treatment so that you can make sure you are the best counselor to help this client, as well as make sure you provide referrals to additional resources in the community. 

Based upon your specific practice or population, you may also find other things are important to discuss initially. Decide on a structure and then stick with it for a certain length of time to see how it works. There have been quite a few times when I was tempted to leave a question out, thinking it did not relate to a particular individual, but was then surprised that it was quite relevant. So once you decide a question is important for your intake assessment, stay with it. Evaluate every 6-12 months to make sure the questions you ask are still relevant. 

You may also want to consider what has been helpful for you in the past or compare this with your own experience of being in therapy and what you liked about the first session or what you feel was missing.

Pay attention to your intuition and to any gut feelings. I have had a few experiences where I felt compelled to ask a question I don't normally ask and the ensuing conversation turned out to be extremely important. So, while I do encourage a basic structure, I think using your clinical judgement is paramount.

Lastly, for insurance clients (even those for whom you simply provide a super bill), I would add a few other things so that you directly address the important topic of medical necessity:

  • Identify the specific behaviors/symptoms that meet criteria for a diagnosis. Make sure to include how these manifest in real life, rather than simply listing off psychobabble terms like "insomnia," "anhedonia," or "hypervigilance."
  • Identify how these behaviors cause an impairment in the client's life. Make sure you can clearly link the diagnosis to a need you can address.
  • List any other treatment providers. If the client has an ongoing medical condition then you'll want to discuss whether or not collaboration is needed since this is often encouraged by insurance companies.

There are many other things to consider when your client is choosing to let insurance pay for their services, but these are the key things to include when you are assessing clients. 

"A client recently asked that I change her diagnosis from major depressive disorder to generalized anxiety. What should I do?"

Here we are talking about the ongoing aspect of assessment, as well as a legal and ethical dilemma. Firstly, a client's diagnosis should always be based upon their presented/reported symptoms. That is why it is important to include these symptoms/behaviors in your initial assessment, if you provide a diagnosis for clients.

To "under diagnose" or "over diagnose" or change a diagnosis without justification is FRAUD. Fraud is both illegal and unethical.

It's that plain and simple. In this particular circumstance, I would discuss with the client what their concerns are, how they came to this conclusion, and why they are seeking the change. I also find it helpful to educate clients about the concept of diagnoses and will sometimes review the DSM with them. 

Hopefully, this creates open communication as well as a better understanding about mental health symptoms and treatment, in general. 

Lastly, I also want to note here that I am not discounting the client's question. The client may actually be right! Perhaps they have not shared certain things, did some research on Google, and were able to read words that described their experience better than they could describe themselves. In that case, it may be justified to document this change in symptoms or new information and then change the diagnosis. 

The key is to constantly assess and to document your ongoing assessment and reason for any changes

So, let us know what you think about these dilemmas! Add your thoughts or tips in the comments below...

Therapy Notes: Your FAQ's Answered

>> Dealing with notes from months ago.

>> Worrying about notes sharing too much information if revealed in a legal proceeding.

>> Spending too much time writing notes because of worries about insurance audits.

These are the concerns many counselors share with me about their progress notes. 

I've been collecting a database of questions I commonly receive about progress notes and figured it's about time I focused on answering some of these!

There’s a lot of information in this post, so here is an outline of everything below:

  1. Writing Progress Notes Late (weeks or months after a session)

    1. How late can I write progress notes if I’m behind?

    2. What can I do if too much time has passed since the session and I don't remember anything to write as a progress note?

  2. How Much To Include In Progress Notes

    1. I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?

    2. How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?

  3. Worries About Insurance Audits of Therapy Notes

    1. I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking.

    2. How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic.

  4. HIPAA & Progress Notes

    1. What are psychotherapy notes based on HIPAA?

    2. It appears that process notes can also be subpoenaed. How do we keep non-clinical case notes for our memory sake?

Remember that my goal is never to tell you exactly how to do something. I am a strong believer in multiple correct answers or ways of doing things (in most circumstances). But I do hope to offer you some food for thought in my answers below.

These are all real questions or concerns brought up by other therapists... and I hear them over and over again: 

1.Writing Progress Notes Late (weeks or months after a session)

"How late can I write progress notes if I'm behind?"

You can (and I would say, should) write any note that isn't written. That means if the note is from last year, write it! If it's from last month, write it! There is no expiration date on writing notes.

Now, if you're like me, there may be an "expiration date" for your memory. And there are certainly expiration dates for things like insurance claims, so that's another story. But having a complete story in your client's record is always important. 

I do recommend that if it's been a long time (this is subjective but let's say more than a month), include something like "Late Entry" at the top of your note. 

You're not trying to hide anything and since you should sign and date all notes on the date of entry, that won't match your session date. This is simply providing an explanation for why those dates are off.

 

"What can I do if too much time has passed since the session and I don't remember anything to write as a progress note?"

Sometimes this happens. And it sucks. 

Do what you can but NEVER make up information that you don't remember. 

If you honestly can't remember what happened but you're certain your client did show up for the session, here is a brief example progress note...

Late Entry. Client attended session. Addressed treatment goals. Next session planned for xx/yy/zz.

Is that a good note? Of course not. But let me tell you, it's still better than no note at all and you're not compromising your integrity. Admit that the situation sucks, create a plan so it doesn't happen again, and move on. 

 

2. How Much To Include In Progress Notes

"I feel I write too much... that is how I remember things actually. Should I then do a summary for the legal notes?"

My short answer is no, I do NOT recommend writing two sets of notes! That’s the opposite of simplifying things. However, I get it because I have a horrible memory due to my ADHD and so I have some other recommendations to improve your case and make them easier to write.

I recommend asking yourself some key questions while writing:

  • What was the theme of our session?

  • What stood out to me as important about our session? 

  • What seemed important to my client during our session?

  • What do I want to follow up on? 

  • What do I think will be really important to have written down for later?

Try to keep your answer to each of those questions to one sentence, then use that as the basis for what you include in your notes. This process may take a little more time initially, but you'll be able to train yourself to think about these things when you sit down to write notes.

Another recommendation is to use my favorite progress notes template so you have a combination of checkboxes AND written data that personalizes the session. This way you can remember what happened, have a complete case note, AND reduce the amount of time you’re spending writing progress notes.

The process will get easier and faster over time. And you know what? You may simply write a little more in your notes than another therapist. And that's okay.

>> It's okay to have good, objective information in your notes. We worry a little too much about having "too much information" in our progress notes. But if you want some more guidance on how to pare things down, check out this blog post where I give an example of how to do that.

 

"How much specific detail do you include regarding session details and/or thought process in how you arrived at a decision?"

Here's a vague answer you'll hate- however much it takes to explain your rationale.

Seriously though, if you're in a situation where you're documenting why you made a clinical decision, you're likely dealing with something that could potentially be high risk or an ethical dilemma or the like. This is NOT the time to skimp on information!

Provide the applicable laws or ethical principles, information from research or consultations you did, and how all of those things contributed to your decision. This is the basis for your rationale. 

Sometimes this can be accomplished in 1-2 sentences, sometimes it will take 1-2 paragraphs. It simply depends on the situation. 

 

3. Worries About Insurance Audits of Counseling Notes

"I'm finding myself writing 1-2 page progress notes. Since I've started taking insurance, I've become stressed with note taking."

Notes for clients who use their insurance aren't drastically different from notes for clients who pay privately. The biggest difference with insurance is that you want to consider medical necessity. 

I have a much more detailed blog post on insurance requirements for writing therapy notes, but I can summarize by saying that you do want to make sure you're following a treatment plan that is focused on the client's diagnosis and you want to address two things in every case note:

  1. Progress made

  2. Ongoing need

This is the fine line with insurance. If therapy isn't helping your client in the long-term, they may choose to no longer pay or not to approve further sessions. However, if you only focus on progress and your client is getting better then it can appear your client no longer needs services.

>> Insurance is usually not concerned about your specific interventions or treatment modality (although it does apply in some cases). They simply want to see that they are paying for a service that is meeting the member's needs. 

And yes, they usually do want to see how they can do that more cheaply. Let's be real. So make sure you consider that, too.

Ask yourself these questions when writing counseling notes for clients who use their insurance:

  • How is ongoing therapy keeping your client from deteriorating, or from needing more intensive treatment?

  • How is therapy improving their health or relationships?

These are all things that make therapy a very cost-effective treatment when compared to things like hospitalization or tests for somatic presentations of symptoms. 

 

"How to document in a problem focused way to satisfy insurance, disability, etc when the session is strength based and optimistic."

Continuing our discussion from the answer above, you want to include honest information about the progress (or lack thereof) that your client is making, as well as their ongoing need. 

Personally, I work from a strengths-based perspective, but that doesn't mean I'm ignorant to the reason my client is seeking therapy.

They have a concern and that manifests itself in ways that are impacting them negatively. To gloss over this or pretend it's not a concern is actually quite demeaning, disempowering and invalidating.

Documenting this and addressing it is a critical component of enacting change and working through any problem. Documenting this problem does not place blame on the client or invalidate any of their strengths. In fact, it does quite the opposite.

So yes, include the strengths and the wins. Absolutely. 

And then also include what continues to be a concern, a problem, a need. Identify what didn't work or continues to be a struggle.

>> Document the full journey your client is on and you'll have a beautiful narrative that highlights their resiliency and strength throughout. 

 

4. HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

This is a BIG topic and for a more complete answer, I recommend checking out this post on what you MUST know about process notes. But here are the basics with psychotherapy notes per HIPAA...

  1. Psychotherapy notes are what we commonly refer to as process notes.

  2. Psychotherapy notes are optional and MUST be kept separate from the client record to receive their distinction.

  3. Psychotherapy notes are NOT progress notes (case notes) that discuss ongoing treatment.

Why they decided to use such a confusing term, I'll never know! But per HIPAA, psychotherapy notes are those optional notes you might write to yourself about sessions or clients, to jog your memory, etc. As such, they receive special privacy and clients are typically not entitled to them. 

However, these never take the place of progress notes, which are the ethically and legally required notes all therapists do need to take. 

So yes, if you choose to write process/psychotherapy notes, you are choosing to write two different notes for sessions. For some therapists, this is a really important part of their own process. For others, it is simply an extra burden and they choose not to do it. 

In case you're wondering, no, I don't write process notes myself. But I also share notes with my clients on a regular basis, so I often do things a little differently ;) 

 

"It appears that process notes can also be subpoenaed. How do we keep non-clinical case notes for our memory sake?"

Yes, they can! It is a common misconception that process notes (psychotherapy notes as discussed in the previous question) receive such special treatment they cannot be subpoenaed. 

However, it is very rare that psychotherapy notes are ever subpoenaed and I would guess that if they are, whomever is requesting them is often intending to request progress notes instead. It is always best to call your client and discuss the reason for the subpoena, see if they are providing consent to release records, and to then assert privilege when applicable. 

Unfortunately, since the definition of psychotherapy notes is basically any notes you take about clinical treatment for your own purposes, I can't think of a way to ethically do that so they are never potentially subpoenaed. 

Remember though, that process notes can be whatever you want them to be. That means you can use abbreviations, shorthand, your own illegible handwriting... whatever you want! You do not have to worry about these notes being ready for scrutiny. 

>> That being said, the one thing I would encourage you to consider is how your client may react if they saw the notes. Although it is highly unlikely that will ever happen, you wouldn't want to have anything that could be offensive. I'm not saying to avoid writing things that are true, but do consider how you word things. 

 

Want to see some actual examples of progress notes?

Click below to join the Private Practice Paperwork Crash Course and you’ll get immediate access to a FREE mini documentation training, complete with progress note examples and a treatment plan template.

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? 

Paperwork Tips from Experienced Therapists

Paperwork Tips from.png

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! (Edit: the Webinar CE Club is no longer, but you still get access to all my ote writing tips and trainings in the Meaningful Documentation Academy!) 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!

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!