Better, Faster Treatment Plans

Treatment plans are the number one thing people search on Google to find QA Prep! That tells me there are LOTS of questions from mental health therapists about this topic.

In this quick video I'm sharing with you one easy way you can improve the quality of your treatment plans while also saving yourself time.

Not too keen on watching a video? Then read the highlights below!

I'm not quite sure why treatment planning turned into something we have to do for paperwork's sake instead of something we do for a real purpose. But unfortunately, it did. And I hope to change that. 

One easy way to make your treatment plans more meaningful to you and your clients is to write the treatment plan with the client in the room.

I know, I know... a lot of clinicians don't like to do this! They're worried that doing paperwork with a client will negatively impact the relationship and create a barrier. However, when done with care, it actually has a different impact. 

Here are some benefits of writing treatment plans with clients:

  • You'll be able to use your client's own words to describe their concerns, needs and goals
  • You're able to receive immediate feedback on what they want out of therapy or how they view the counseling process
  • You can share with them what your involvement is in the therapeutic process

So, if you've never tried doing this before and treatment plans are a hassle for you, try it out! Let us know what you think in the comments below.

Step-by-Step Intake Progress Note

Did you know that your very first progress note should look different from your other client case notes? 

That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;) 

In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.

I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):

  • Limits to confidentiality
  • Potential benefits and drawbacks to treatment
  • Consent for treatment
  • Attendance policy
  • Communication outside of session
  • Reason for seeking treatment
  • Assessment of symptoms
  • Assessment of biopsychosocial data
  • Plan for treatment

Some sections may have more or less detail, depending on the client's situation or length of the session.

For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions. 

When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.

Want to see an example note?

I've got one for you! Check out this sample note below to see how it looks when we put it all together. I'm using the DAP note format here...

Data: 

Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks. 

Assessment:

Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.

Plan: 

Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.

You're probably thinking, "Does my note need to be that detailed?"

Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.

On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer

Notice that this note doesn't include anything I would have in my intake assessment form.

That's because I see no reason to write the same thing multiple times!

This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation then why do you need to write these things over again in your intake note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.

So, if you miss something on your intake assessment form then write it in your intake progress note and vice versa. 

I've got a checklist you can download to create your own intake note template or to use as a reminder when writing your intake notes.

Enter your info below to sign up for my weekly emails and then check your inbox to download the checklist! Remember to check your spam or junk folder.

We keep your information secure via our Privacy Policy.

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...

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

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

Paper Records

Pros:

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

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

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

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

Cons: 

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

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

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

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

The In Between

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

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

Electronic Records

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

Pros:

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

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

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

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

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

Cons:

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

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

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

Some Cons to All Methods

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

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

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

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

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

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

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

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

Do a review of your client's file.

Before you stop reading, let me explain!

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

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

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

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

1. Go back to the very beginning.

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

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

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

2. Evaluate your treatment plan.

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

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

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

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

3. Review your notes from day one.

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

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

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

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

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

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

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

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

When Outcomes Don't Matter

I've been thinking a lot recently about the process of everything and not being so focused on results. While this is part of my own personal growth, being the documentation diva I am, I began to think about how this relates to our paperwork. ;) 

I believe in outcome measures and think they can be valuable clinical tools. But they're not everything. What about the process? 

If a client engages in therapy for a month and doesn't connect with the therapist and drops out, was that meaningless?

Was their lack of progress the therapist's fault? Was it their own fault?

Or was it merely a step in the process of discovering what type of therapist this client connects with?

We won't be "successful" with all clients. Not all clients will have the same amount of growth or progress. 

In these circumstances, what can our outcome measures tell us? I believe it's more than just "you suck as a therapist" or "that client was being resistant." They tell us something about the process

So maybe the problem with outcome measures is we're not using them to their potential. Maybe they're not just about a rate or amount of improvement. Maybe they're also about where we are and where our clients are in the process. 

I was talking with a therapist the other day who sends out surveys at the end of treatment. They are anonymous and ask questions about how the process of therapy with this particular counselor worked for the client. I was so impressed by her openness to the responses.

There was an administrative issue identified in which many clients felt she could improve. She agreed with this and it confirmed for her what she was suspecting. Beyond that, she was taking steps to improve this process.  

So, her "outcome" was poor. But look what that did! Sometimes we need something objective to show us more clearly how things are so we can recognize where we are in the process.  

If I give a client an outcome measure at day one and day 90 and see little improvement, that's not a failure. But it is necessary information to have. There are lots more questions to ask at that point...

What's going on?

Was this result a surprise or expected?

Do we feel like we're measuring the right thing?

If this was a surprise, how come?

Are there other questions we could ask or measures we could use and obtain a different result?

How do we feel about this?

Do we want to continue with the process we've been using and why or why not?

Can you imagine what an awesome and in-depth clinical conversation that would be?! And all from an outcome measure being used as a tool. A starting point for discussion.

This is why I always say your documentation should work for you and not the other way around. Paperwork doesn't have to be separated from the clinical process. It can be really impactful. But it's all in how you use it.

If you're looking for more help with how to make your documentation meaningful to you and your clients, check out my upcoming workshops (now inside the Meaningful Documentation Academy) or my paperwork packet. It doesn't take a ton of effort, just a little guidance and support... and an open heart. 

What I Learned (about paperwork) from the Road to Success Summit

I had such a great time putting on the Road to Success Summit in June and I learned soooo much from all the experts I interviewed. It was pretty cool to do the interviewing because that means I aaaalllll the content!

I knew the Summit would be helpful for therapists in private practice and my goal was to cover as many different areas as possible. But there was one thing quite obviously missing... a lesson on paperwork!

So, I thought I'd take this opportunity to highlight how your documentation relates to everything in your private practice. And if you're interested in an opportunity join the LIVE version of the Summit, click here to find out more.

Below are the lessons I learned from all the experts who participated, and how it relates to your paperwork:

Casey Truffo and being the CEO of your private practice

-Casey dropped some major knowledge bombs about business in general and has such an easy way of explaining things. The big thing I got related to paperwork was to outline everything you do. Take the time to write out your process so you can later improve, refine and duplicate when needed.

Kelly Higdon and integrating coaching into your practice

-Kelly talked about the differences between coaching and therapy. One of the big differences was the intention behind the service you plan to provide. You might actually be working on the same area (stress at work, for example) but choosing a different way to focus together. And that means, your paperwork will look different! Kelly pointed out that with her coaching clients she actually takes notes during the session and sends them the notes. I do this with my individual consultations as well. We cover a lot so this way the client can stay focused!

Keri Nola and using your intuition in your private practice

-Keri and I talked a lot about the finer nuances of using your intuition in every part of your practice. I think this applies to your paperwork, as well. Don't just include things because you feel you have to, think about how you'd like to write. Never seen something in someone's intake packet but feel led to include it? Then do so! Listen to your heart as well as your ethical guidelines.

Jo Muirhead and creating a successful money mindset

-Money was the topic of Jo's interview and we discussed a lot of the ways we misperceive things and sabotage ourselves by often avoiding the topic. I see a lot of therapists uncomfortable with money and that impacts client care. Because if you're not able to create a clear plan and decide how much you need to charge to sustain your practice, you'll end up reducing your rates out of fear (and often telling yourself it's really out of client need). However, if you have a clear plan that's represented in your policies then that frees you up to provide pro bono or discounted services to those who need it without feeling resentful

Camille McDaniel and adding clinicians to your practice

-Camille brought up some excellent points about hiring and planning ahead. One of things this highlights is being really clear about the conditions of employment ahead of time and also very clearly outlining any conditions of subletting your space. One example she brought up was making sure her subletter's clientele was similar to her own so there weren't potentially awkward situations in the waiting room. 

Rajani Venkatraman Levis and building your practice through community, not competition

-Rajani is one of my favorite people on the planet. That has nothing to do with paperwork but I just want you know how awesome she is. Anyway, Rajani talked about the power of reaching out to others for support, without worrying about whether or not they might be your "competition." It's so crucial to have regular access to some clinicians whose opinions you value so that you can receive feedback when needed. Changing your forms or not sure how to write something up? Call someone you trust so you can talk it through!

Roy Huggins and using technology to serve your clients

-If you know Roy, then you were not surprised that this interview was packed full of extremely useful info! He talked about how the internet actually works and why that means it's our job as a counselor/therapist to review with our clients any risks with technology. Make sure you have a statement in your informed consent about those risks and then document reviewing them with your clients.

Melvin Varghese and starting a podcast 

-Melvin shared some very practical steps for how to start a podcast, as well as the tools he uses for his own successful podcast. He also talked about monetizing his podcast recently and how valuable it has been for creating authority and networking with other professionals. How does this relate to paperwork? Well, do you have a place for clients to write down where they found you? This will help you to gear your marketing efforts toward what is working best. And maybe, that's a podcast!

Ernesto Segismundo and using video to promote your practice

-Okay, I'll be honest, it's difficult to tie this interview into a documentation lesson. But you know what? I think Ernesto really highlighted why video is such a powerful tool. What if you had a video on your website explaining your intake process, rather than just telling people to download forms? The more interactive and personalized you can make things, the more your clients will appreciate that effort. And boy, will it make you stand out as going the extra mile!

Kat Love and creating a beautiful website

-Kat shared insight into how to create a website that is appealing your clients. This is huge because you're competing with all sorts of distractions online. Since my focus is on making your documentation meaningful to both you and your clients, this really begins with your website copy and presence. Make sure everything flows together smoothly. Use a lot of casual language and pretty colors on your website but then have very stoic sounding forms that are all black and white? That's a mismatch! So continue your branding from website to forms to service.

Clay Cockrell and providing counseling online

-Clay provides counseling online and also runs a directory for other therapists who provide online services. Since this whole online counseling thing is so easy for him, he shared sooooo many resources and tips! One big tip? Create a plan for what you'll do when technology fails, because it will at some point. If you're providing counseling online, include this in your informed consent form or create a separate document that explains what you'll both do (for example, will you call the client or should they call you?). This can decrease any stress that may occur, for both you and your clients.

Barbara Griswold and responding to insurance inquiries

-In Barbara's interview we talked about dealing with insurance companies and she shared a lot of the mistakes she sees therapists make. One of the big things is thinking they don't need to worry about insurance ever seeing their paperwork. Although it's not super common for insurance companies to audit your files, it does happen. And the way in which you document can impact whether or not your client's services will be rejected. So, even if you're just providing a super bill, make sure you're well informed about what's needed.

Samara Stone and building a practice based on insurance

-Samara talked about why it's important for her to have a large practice that bills insurance and also shared some of the mistakes she made early on when using insurance. One of the biggest mistakes was being unfamiliar with the billing process. Once she decided to suck it up and learn what was needed she was able to make sure billing was going smoothly. And, that allowed her to know the right person to hire when she needed to outsource that task because of the time it was taking. 

Nicol Stolar-Peterson and creating a court policy

-In Nicol's interview I tried to start off with "what do we do when we get a subpoena?" and Nicol let me know we had to back up first! Why? Because responding to legal requests and whether or not you get paid to do so is all about what you have in your court policy. So make sure you've outlined that ahead of time and don't get caught losing money while waiting around in the courthouse just to assert privilege. 

Agnes Wainman and identifying your ideal client

-Agnes talked about why it's important to identify an ideal client and then actually walked me through some exercises to do that. But marketing isn't where this stops. Make your intake paperwork speak to your clients, as well. Continue that relationship from whatever made them call you to them completing their forms and walking in your door to the two of you working together. If your forms are personalized to their needs, they'll immediately feel a sense of relief for taking the step and reaching out to you. 

Allison Puryear and networking your way to success

-Allison and I talked about how you can choose networking strategies that are specific to your personality and work with your strengths. Wondering what to talk about when you meet with other therapists for networking? Ask them what type of notes template they use! Trust me, most counselors are actually interested to talk about it because they're dying to hear what you do, too!!

Stephanie Adams and creating systems that sustain your practice

-And we're back to where we started... with systems! Stephanie focused on the ways in which creating systems for her practice has saved her time and stress. One of the first systems I recommend you automate and really spell out is your intake system. How do you give clients info in the beginning, how do they sign and read forms, how do they pay you, will you remind them of their first appointment and when, etc. Writing this all out will save you a lot of stress in the long run.

If you didn't get a chance to watch all the interviews, then check out the interviewees who sound the most useful to you. They ALL have great resources to be used at different points in your practice.

Also, make sure you're signed up for my weekly newsletter so you never miss info on awesome stuff like this! I've got a few things planned coming up, including some live workshops across the U.S. You won't want to miss it!

How to Personalize Your Intake Assessment Form

Whenever I meet with clients for the first time, I make sure to have a form with me so I stay on track. Even though I've done tons of assessments using the same form, it's so easy to miss something important when I don't have that friendly reminder. 

Having a good intake assessment form is crucial to doing a good intake assessment. Ideally, the form simply serves as a means to guide and document your clinical conversation. It's a valuable tool in the moment, and also if you need to remember things down the line. 

That being said, creating the form can take a bit of work to individualize and then there's the task of familiarizing yourself with it so you actually focus on the client during your intake, not the form

That's why we're breaking things down in this post. I'm going to review with you each of the sections of the intake form in my Therapist's Perfect Paperwork Packet so you can identify which sections in your form you may need to add more detail or which areas to take away some extraneous information. 

Note: People use different terms for this form but the form I'm talking about is your clinical assessment, or biopsychosocial assessment, completed during the intake phase of treatment (typically, the first 1-4 sessions). 

Client Contact Information

You may have this elsewhere in your intake paperwork but I like having some details on client demographics directly on the assessment itself. How in depth you go depends on the information you feel is important to your practice. You'll at least want to include basic contact information, emergency contact information and how to best reach your client (including whether or not voicemails and texting is okay). 

Other things you may want to consider are languages spoken, ways in which your client found you, military rank/position, email, work phone number, etc. Think about the things you wish you had asked before or info you found helpful and include that.

About You

I like having a section that allows the client to describe themselves a bit. This way you get to see the language your client uses for things like hobbies and interests. You can also ask for personal strengths or for preferences. You may want to ask about things like typical screen time or favorite games if you see children. 

I also include a section here for clients to describe their goals for treatment. This way you get to see what their thoughts are about therapy in general and why they've come to see you, in particular. This serves as a great starting point for discussion.

Family History

Gathering information about family history is very important for determining the level of familial support a client has, as well as potential indicators for patterns of behavior. You'll want to identify key relationships, especially those that include an aspect of dependence like care-taking for children or elderly parents. 

One important thing to consider here is that everyone has a different definition of family. I always include a question about "who lives at home?" so I capture anything I may be missing. You may also want to go more in-depth and have clients describe (or circle options) about their level of closeness with different family members. 

Employment/Education History

This area may change greatly based on your client population. Obviously, if you see children you would choose to focus more on the education aspect. However, you may want to include a question about the parent/guardian's occupation. 

We can get even more detailed here: If you see children who tend to be involved with special education services, you may ask more detailed questions about behavior at school, classroom setting, previous grade retention, etc. But, for example, if you tend to see adolescents with anger problems you may focus more on interpersonal interactions ask about suspensions.

When working with adults, employment can sometimes indicate being part of a sub-culture, like with people in the military. In this case, consider questions that would be client specific but potentially impactful to treatment. In the military example, you may want to ask about rank, length of stay in current assignment and any deployments.

Or perhaps you see women who often describe themselves as "stressed" and so you choose to add a question about typical hours spent at work each week and/or a rating of their current work stress. Likert scales are very easy to use here (e.g. a range from "Very Stressed" to "Not Stressed").

Hopefully, you're beginning to notice how all of these questions easily intertwine with the clinical topics you'd want to discuss during your assessment phase and also allow you to see how this process can naturally flow, rather than just sound like paperwork review.

Medical History

This is another topic that will vary greatly depending on your typical client population. If you work with elderly clients, for example, you may want to ask more detailed questions about medical history. Likewise, if you work with couples who are having difficulty with their sexual relationship you'd want to make sure each member of the couple has had a physical exam very recently. 

This is also where you'll want to get information about your client's physician and psychiatrist, if applicable. Many insurance companies particularly look for you to gather this information so you can collaborate as a treatment team.

Mental Health Treatment History

One of the key things to consider with new clients is whether or not they've been in counseling before. This is important to discuss as you inform clients about what it's like to work with you and whether or not you'll be a good fit.

See what we're doing now? We're integrating informed consent with our intake assessment! Documentation is such a beautiful thing ;)

What are their feelings about coming to counseling? Have they had negative or positive experiences in the past? Are they hoping to revisit similar issues or focus on something very different? What did they like (or dislike) about their previous experience and what did they find helpful? 

You may not include all of these questions but consider what typically arises with clients when you discuss these things. What would be helpful to have clients consider ahead of time so you can address it easily during intake? Those are the questions to include. 

Substance Use History

Again, depending on your typical client you may add more or less detail here but regardless, it's very important to cover with clients. If you see clients where this is a common issue then you may have a whole page where ask people to identify use of certain types of drugs, daily or weekly amount of use and prior use. 

You'll also want to ask about whether or not your client is connected with any other support, like a peer support group or substance rehabilitation program. If so, you'll also want to consider whether or not it may be appropriate to consult with these professionals and how your client feels about that. 

Other

There are plenty of other topics to discuss with your clients but you can't know it all before you actually begin the work. The consideration here is whether or not you think it's something to know from the outset or decide if it's something that may come up naturally during the course of treatment. 

Topics also included in my intake assessment form are things like religious affiliations, spirituality, coping skills and favorite habits for self-care. I also include a question on whether or not a client has ever been arrested and if they have a current parole/probation officer.

Another important thing to consider (that may also be part of your informed consent) is whether or not your client is currently part of any litigation/court case. Definitely something you want to know as early as possible so you can review any potential conflicts or expectations of the client.

So whether you prefer to create your own form from scratch, revise whatever you have now, or purchase my Paperwork Packet, you've got plenty of options for how you can make the intake process individualized to your clients and your practice. 

That's my biggest piece of advice for every aspect of your documentation... make sure it actually makes sense and isn't completed "just to do it." Paperwork has meaning but that's only as deep as the meaning you assign it. 

What other topics do you include in your intake form? Comment below and share your own tips!

Choosing a Treatment Plan Template You (and your clients) Like

Search around you'll find lots of different types of treatment plan templates. Which one is better for insurance? Which one do I need to use to show I'm being ethical? Do I really need one?

These are questions I get all the time. Well, as in most paperwork situations, the answer is... it depends! 

So let's break things down. Yes, you should have a treatment plan for all your psychotherapy clients and no, there is no special requirement for which type of treatment plan you use. This can be both liberating and frustrating for counselors because you have flexibility but little guidance.

That's why I'm here ;)

Let's look at some different types of treatment plans and in what situations they work best...

Narrative

A narrative treatment plan may be as basic as writing out what your client says they would like to achieve in therapy. This may be a simple phrase or 1-2 sentences that you include in your session note, or even on a separate "treatment plan" document (or section of your practice management system). 

It's not very structured and doesn't require a lot of thought. This is great when you're working with clients who are very comfortable with the therapy process and may not need as much check in regarding specific progress. It's also a good fit if you are comfortable remembering the general topics your clients are seeing you for and just need a "home base" of sorts to check in with every once in a while. 

This is also a pretty common form of treatment planning... and a nice alternative if you're the type who never really writes anything down and shy away from a structured form.

Structured

Some counselors prefer to have something more structured. This takes away the ambiguity and allows you to create a framework. If you've ever looked up treatment planning books or worked in an agency, you likely found structured treatment plans that had specific categories and encouraged you to detail progress at certain times throughout treatment.

If you have no idea where to start, using a structure plan can be very helpful. Once you become familiar with the structure, you're able to easily discuss the plan with clients and complete the form quickly. 

Remember that even with structured plans you should make the treatment plan as individualized as possible. Simply choosing from a list of interventions or problems is typically not very meaningful and focuses more on doing the form than actually creating a successful therapeutic journey. 

Diagnosis based

Many structured plans that you'll find for purchase are based on diagnosis. These plans encourage practitioners to choose a problem focus (e.g. generalized anxiety or suicidal ideation) that relates to a particular diagnosis. Then the therapist will identify treatment interventions that relate to the particular problem.

There are benefits and drawbacks to this type of treatment plan. The benefit is that you can present a list of items to clients who may have difficulty identify goals or problems on which to focus. These plans also provide you with specific ideas for interventions that relate to diagnostic issues.

However, it is very easy to fall into the trap of not including your clients in this type of treatment planning process. Because the plan is often based on more intensive or negative behaviors, you may prefer to discuss generally with the client and then integrate that into the formalized plan later and on your own. This increases the amount of time you spend on treatment planning while also potentially making the plan less meaningful to your client

Client-centered

Rather than focusing on symptoms or diagnostic categories, client-centered plans focus on the client's identified goal for treatment. These plans may ignore external requirements for treatment and focus on integrating what the client chooses to bring to the session. 

That means you may choose to focus on something like improving communication or self-esteem, things that may or may not be associated with an actual mental health disorder. While every treatment plan should really be client-centered, these don't focus on ensuring the client meets specific criteria that may be important to other entities (e.g. insurance). 

So really, you have a lot of flexibility with treatment planning... but you can also give yourself varying levels of structure as needed. If you're looking for more structure with treatment plans, I offer a packet of 6 in my Therapist's Perfect Paperwork Packet (available June 20th). 

Or you can sign up for my FREE Private Practice Paperwork Crash Course and get one free template you can use right away. Either way, I've got you covered so you can focus on doing great work with your clients!

Simplifying Your Informed Consent

Informed consent is a whole process, not just a form. And it very easily gets convoluted, long and confusing. But it doesn't have to! 

We can make the process a lot more simple and easier for both ourselves and our clients (I mean, it's really for them so we may as well make it simple, right?!). I've got some tips below to help you cut out the confusion.

Make it a conversation

Informed consent is NOT a form... it's a process and a conversation you have with your clients. So use the key points you want to highlight and think of them as talking points instead. These are ways to introduce your clients to the parameters of the therapeutic relationship.

The paperwork is just a representation of the conversation you have.

Give examples and explanations

Since it's a conversation, make sure you use stories and examples to explain the concepts. For example, confidentiality may be a bit ambiguous to some clients. But if you provide some common scenarios that relate to your client it can become much more clear, opening up the opportunity for clarification before a situation gets awkward.

For example, if you notice that your client's address is very close to your own you may bring up the scenario of how you would respond if the two of you saw one another in public. Or you may discuss with a client who prefers texting the possibility that others may see their appointment reminders on their phone's home screen.

And if you work with children or teens, I definitely recommending having a detailed conversation about what kind of information will or won't be shared with parents and how that might happen.

Use layering

The things you need to include in your informed consent constitute a loooooonnnnnnggggg list. It's not realistic, or even preferable, to review everything in the first session or two. Instead, choose what is important to discuss based on what your client presents.

Yes, there are certain things you should discuss with everyone right away, like confidentiality, how to get a hold of you and how much you charge for a session (and a missed session). But most of the rest you can adjust as needed.

Highlight the main points in your informed consent and clarify any questions. Then use your clinical judgment about the areas in which you may need to go more in depth. 

Your client mentions they'd prefer texting reminders? Go in depth about that topic. Your client says nope, no texting? Then no big deal. Remember, this is a process, not a form. So you will revisit things as they come up... like when that client eventually DOES text you they're running late ;)

Ask your clients about different topics to see what matters most to them. See if they have any questions about your policies. Talk to them about any prior experience in therapy and if they have questions about things you may do differently. These are all great ways to get the conversation going while simultaneously reviewing informed consent. 

If you still want some more details on this topic, check out the webinar I did with Roy Huggins from Person-Centered Tech. You can earn one CE credit for watching and get even more great tips!

And let us know in the comments below... how do you review informed consent?

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

What is a Notice of Privacy Practices?

You may have heard about a form called the Notice of Privacy Practices but not really be too sure what it's all about. In this video I'm helping to clear all that up! Click below to watch...

While the Notice of Privacy Practices is a complete form, the main aspects that apply to therapists in private practice include:

  • Your record keeping policies
  • Your client's access to records
  • How you share client information
  • Opportunities for clients to file a complaint

Healthit.gov provides an excellent sample form that is both visually appealing and covers all the necessary bases. Click here to view the sample. 

Remember that even if you're not a HIPAA covered entity, many of these principles are still considered best practice to include in your informed consent process. 

The key, as with everything, is to determine how these principles apply to your clients and use that for discussion. Let us know in the comments how you include these principles in your forms!

How to Organize a Client File

Many therapists struggle with the lack of direction given regarding client files. How do you organize a file for private practice? What needs to be in the file, other than notes? Are there any standards?!

While there are some standards regarding what should be in a file, there aren’t many standards regarding organization. Most large agencies do have similar ways of standardizing files and I recommend following that type of mindset.

Follow the timeline of their story with you. Basic organization usually follows a chronological story and has a clear beginning, middle and end. Think about what happens when a client contacts you, their first session, and things moving forward until treatment ends. Easy, right?!

Now, this mostly applies to those of you who keep paper files since electronic health records organize things a certain way and you typically have little flexibility. But most of them probably also follow this chronological timeline.

So, let’s dig into the specifics… I’ve got various sections of a client file listed below, all in the order I recommend you include them:

  • Intake information- this includes demographics, contact information, and any type of client assessment form or questionnaires you complete during the intake/assessment phase.

  • All signed documents- this includes informed consent, social media policy, court policy, credit card authorizations, releases of information, etc. Anything your client signs as acknowledgement or agreement should be included in their file.

  • Treatment plan- this may be a quick note or a more formalized treatment plan template that you use. Regardless, we ethically need to have some sort of treatment plan. I recommend keeping it here as it serves the purpose of connecting what is originally identified as the client need and how that’s addressed in session moving forward.

  • Notes in chronological order- these are all your interactions with your client. The largest chunk will be your regular client sessions, documenting no shows or cancellations as well. This also includes notes on texting, emails or other outside interaction. While I don’t think it’s necessary to print out or copy and paste every email or text, it is important to document interactions you have with your clients. Remember, you’re telling a complete story.

  • Reports or correspondence from other providers- you may or may not use this but if you receive info from other professionals, include that in a section near the end.

  • Other correspondence related to the client- this is sort of your catch all for things like letters or any other type of communication that may not be related to other professionals.

  • Insurance- if you work with insurance directly you’ll want to make sure you document any requests, correspondence or billing related matters.

  • Other- Artwork, letters, etc. Lastly, the true catch all for anything else you can think of! These may be exercises you complete during session. Some people choose to keep more sensitive projects (for example, a trauma narrative) separate from the main file in order to protect confidentiality. That is also an option.

So there you have it! A complete, organized client record.

What insights did you gain from this article? Anything you plan to adjust? Let us know so we can help one another out!

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

Mental Health Paperwork: Get Organized and Save Time

There are lots of things we never learned in grad school. Lots of really basic things you need to do every day if you own a private practice! And one of those things is dealing with administrative paperwork so it stays organized and doesn't take up all your clinical time.

If you've read any of my other blogs you know my big "schtick" is making your documentation meaningful. I find making that connection with paperwork eases a lot of the anxiety counselors commonly feel. However, sometimes you just need tips on making things more efficient so it's not as time consuming. And that's what we're talking about today!

Administrative Paperwork

1. Have clients complete paperwork ahead of time.

There are a variety of ways to do this but having clients spend some time reviewing your forms, policies and maybe even completing an assessment form before first talking with you will allow you both to focus on what is most important in that first session.

If you use an EHR, you may allow clients to log into a client portal and easily complete forms and sign paperwork that way. Or perhaps you email clients a welcome packet, along with directions to the office and an appointment time confirmation before each session. You can also have forms available for download/viewing on your website and direct clients there. Lastly, you can even tell clients to arrive early and simply have paper forms waiting for them to complete.

Regardless of which method you use, I recommend sitting down and completing your forms yourself, as if you were a client. Complete them to the best of your ability and time yourself. How long should clients allow to complete this task? Now you have a realistic idea and can let them know what to expect. This little customer service step can make a big difference.

2. Review forms with your clients in person.

Even when you have clients complete forms ahead of time there are certain things you need to review in a personal conversation. You’ll want to make sure you review things like limits to confidentiality, fees, risks and benefits of therapy, getting a hold of you in emergencies, no show and cancellation policies, etc.

Keep your forms visually friendly in order to aid this process in moving along quickly and easily. Use titles and bullet points so you can highlight the key points and make sure your client understands each item. Then you can easily “sign off” together (if you haven’t already done so electronically).

Remember that all of these things are actually an ongoing conversation with your clients. You’ll likely need to revisit certain things at different times and you don’t have to cover everything in the first session. Many counselors use the first 2-4 session as an “intake period.”

3. Do your assessment form via conversation.

Perhaps you prefer to do your assessment form together with your client. Awesome! This is another great strategy for getting paperwork done in a timely way while also connecting it to the clinical work. Make sure you know your forms well and can easily flip through pages based on how the initial conversation is going. There is nothing worse than someone stopping you mid-thought to go off an interview script.

So be flexible and let your client choose the direction while you complete some of your paperwork. Ask questions as needed and keep things focused on how you can help the client. There may be some things you need to ask that are not voluntarily brought up by the client (history of substance use, for example). Gently explain your purpose for the assessment period and the fact that you understand some things may initially be uncomfortable but honesty will benefit the therapeutic relationship.

Explain that you’ll be taking notes and value their input along the way. I find most clients are very understanding when completing forms like this when they are part of a natural conversation. 

Organization

1. Use an electronic health record (EHR)

There are few steps you can take to improve your organization in private practice as much as using an EHR. Also called practice management systems, these provide a one stop shop for notes, treatment planning, scheduling, billing, securing client data, etc. Yes, it takes a little time to set up and get used to whatever system you choose but it is well worth the time investment for most therapists.

There are many EHR’s out there and if you’re confused about where to start I recommend checking out Tame Your Practice, where you can find reviews on just about every system out there and make the best decision for your needs. Also, make sure to bookmark my guest post where I review Tips for Transitioning from Paper to Private Practice EHR.

2. Use a billing expert.

It only takes one “bad” claim to eat up three hours of your day. That’s why most counselors just ignore these claims entirely and choose to take a loss- the money they’d earn isn’t worth all the time it takes to retrieve it. However, if you use a billing service you can avoid all that hassle.

Yes, they will take a percentage of each claim you bill but considering the incredible stress claims put on most therapists, it is worth every penny. Shop around and make sure you choose someone who specializes in mental health billing. Try them out for a period of time to make sure everything is working. You can also check out Barbara Griswold’s Billing Service List, which is a list of national billing services rated by other therapists.

3. Integrate your calendars.

Lastly, integrate your calendars and scheduling tools as much as possible. Especially in the beginning of starting a private practice, many counselors have clients on random days and times because they have more availability. This can easily get out of hand as you become more busy and keeping everything in your head is a sure way to make a mistake in the future.

4. Alphabetize everything.

When you only have 2-3 clients it’s fairly easy to keep track of everything… not so when you have 20-30! And it is very easy to experience overwhelm once those numbers start to rise and you realize keeping track of everything has become more complicated.

Even if you use an EHR there will always be some things you’re likely keeping in a file cabinet or housed on your computer and these should be organized so you can easily find them. Start now by alphabetizing everything- business and networking contacts, CE certificates, client information, etc. For things like taxes or other financial statements, organize by year and month (maybe weekly if you have a larger practice).

Then you’ll easily be able to file things away and find things later on. Little tasks like this are huge for decreasing overall stress and avoiding big mistakes.

If all these tips feel a bit overwhelming, choose one and start from there. No one taught you this stuff and there is a lot to figure out for yourself. One of the biggest mistakes I see many therapists make is trying to do what a supervisor or colleague did when it doesn’t work as well for them. Test things out and adjust as needed.

Find that you hate using an EHR? Ditch it and go back to paper! In that particular circumstance I’d recommend giving it a good try first, but seriously… do what works for you, your business, your clients.

Now let us know in the comments what organizational tools help you with paperwork the most? How do you save time on administrative tasks? I’d love to hear about it!

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

How To Do a Yearly Review of Your Policies and Forms

A yearly review of your forms and policies can save you time and heartache in the long run. "That seems a bit dramatic, Maelisa" you may say. But exaggerate, I do not! Let's look at a couple scenarios...

  • Perhaps you continue to have clients using a sliding scale fee when they no longer need this fee. 
  • Maybe you're still procrastinating on that social media policy and get nervous every time you see a friend request or a new follower on your social media accounts.
  • Or perhaps you've been avoiding emails with new clients and spend extra time on paperwork during intake sessions.

These are all things that can be streamlined or revised. So how come so many counselors avoid doing these things? Because it seems boring and time-consuming in the moment!

However, revising (or creating) your social media policy may only take you 15-60 minutes (for the whole year!)... but could save you an hour of consultation with colleagues and then another hour in session when you get that inevitable friend request or follow.

Creating a structure around your intake forms and systematizing email communication can save you 1-2 hours for every new client but may only take a one time session of 1-2 hours to set up for the (foreseeable) life of your practice. 

Now, most likely if you're reading this you already have your forms and policies set up. You're just scared they may not actually address all the potential issues that could come up and may be incomplete.

Below I have some questions for you to ask yourself. So, take a moment right now to get out your intake forms and internal policies. Yes, get them all out and then come back to this and answer each question below. 

As you go through your forms and notice something is missing or needs revision simply write on the form or highlight it with a note. Give yourself 30 minutes. I promise you'll be done at that point and will have a pretty good review of your forms. 

If you do need to create something totally new or do a more extensive revision then plan an hour at some point next week. Make it non-negotiable in your schedule and also tell yourself you will be satisfied with the result at the end of that hour regardless of how complete it is.

Your forms and policies will never be perfect!

That's why you do the annual review. It's a work in progress and things will adjust as you have new experiences with clients or ethical guidelines change. That's okay. It makes our work exciting :)

Alrighty, now we have your review questions. Go through each question and read your forms to see if anything is needed. Don't forget to set your timer. This is NOT the time for obsessive perfection.

  1. Do I know how long my state or professional association requires me to keep records? Is it time for me to destroy any records from previous years?
  2. Do I include in my intake documentation that when I see couples or families their records may be considered one client record and this may require both/all parties to consent to release?
  3. Does my informed consent document outline the benefits and potential risks of therapy?
  4. Do my intake documents outline my sliding scale policy and identify a timeframe (I recommend 3-6 months) in which to revisit the financial need?
  5. Do I explain exactly when I charge payment (e.g. before session, beginning of day, etc.)?
  6. Have I clearly identified circumstances in which texting and/or email is acceptable and the potential risks when used?
  7. Are any active Releases of Information expired or need revision?
  8. If you are a HIPAA-covered entity, do you explain to clients their rights regarding access to records as well as the limitations on confidentiality?
  9. Is there any language in my forms that appears to frequently confuse new clients or about which I am commonly asked? Is there a way to revise this and make it more clear?
  10. Have I created a professional will so that my loved ones and clients will experience less burden if something should happen to me (whether short or long-term)?

Phew! Okay, that wasn't so bad, was it? Maybe it was even easier than you thought. Keep in mind, this isn't necessarily an exhaustive list of what you may want to review but it certainly covers some key points.

If you want to do a more in-depth review of your intake forms and policies, my Meaningful Documentation program will be opening up again soon. We spend two whole weeks on this topic! You can click here to get on the interest list**.

In the meantime, leave a comment below with anything that came up but isn't listed here. It'll help your colleagues reading this later on. And feel free to post any questions! Let's keep the discussion going.

Happy reviewing!

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

**This group is no longer running, but you can find tips, webinars, and office hours in my Meaningful Documentation Academy.

Money and Paperwork: The Emotional Impact on Counselors

Get a group of counselors together (in person, in a Facebook group, anywhere) and a few topics will inevitably come up... 

How much they dislike marketing and selling (but how they know it's needed for a successful practice)...

Disdain for insurance and difficulty getting paid by insurance companies...

A true desire to help clients and passion for clinical work...

Fear of not being able to do that awesome clinical work and earn a decent living...

I have lots of amazing friends who are therapists and I know plenty of talented colleagues. So how come when we all get together there seems to be a pervasive fear of success and almost innate insecurity about our skills?

Don't get me wrong, that's not the case for all counselors. Many are confident in their skills and abilities as well as business savvy. But I do find that most counselors struggle with confidence. 

We could get into an infinite number of reasons for this and discuss endless related topics. But I'm going to stick with a couple areas that relate to my focus (because I only claim to be the Documentation Diva, not the Everything Diva).

So let's narrow this apprehension down to money and paperwork

This is something I ended up talking about with Matt over on his Virtual LPC podcast. And I notice it comes up with a lot of other counselors on his podcast as well. 

There is this fear that no one will want to pay for our services unless there is some sort of discount. I actually had this come up for myself recently. I immediately went to consider a big discount for a client... before they had waffled in their decision, before they asked about it, and even before I had run the numbers to see if it truly made sense.

Why the heck would I do that?! Because I was scared... afraid that someone wouldn't pay what I asked.

And it was totally irrational. 

I was offering a quality service at a very good price. It was an excellent investment for this customer. They saw the value in it right away and there was really no reason for this fear. 

Now imagine having this sort of fear or apprehension every time a potential client calls. That would be exhausting! And really unnecessary. 

But how do we overcome this? Well, as usual, I've got some tips for you...

  1. Talk about it. The best way to overcome fear is to face it head on. Talk with your friends and with colleagues. Talk with your own therapist. Figure out where any insecurity or fear may be originating and work through it.
  2. Surround yourself with successful people. Notice I used a general word here- people (not counselors or therapists). Make sure you connect with successful business owners. Soak up their strategies, their mindset. Be open to lessons you can learn from business owners both inside and outside the field of mental health.
  3. Surround yourself with generous people. Most of us got in to mental health because we genuinely enjoy helping others. However, this doesn't have to be mutually exclusive to financial success. Spend time with people who are successful and generous. It will not only help your mindset but will also give your more resources to help others.
  4. Read up on money mindset. There are tons of great books that offer inspiration on changing your money mindset. If you tend to have negative feelings around money (whether that's fear, resentment, desperation or lack) then make a small investment in a book or two and potentially see some significant change in your life. I mention one of my favorites on Matt's podcast :)
  5. Create a business plan. This is really freaking practical and necessary. There's no use worrying about money when you don't even have a clear idea of how much you need for personal and business expenses. Lay out everything- retirement, vacations, sick time, groceries, rent, etc. This sounds really intimidating to a lot of people and is something many of us avoid. However, this one thing will help you clear a lot of anxiety and get very focused on where and how you focus your philanthropy. 
  6. Incorporate a sliding scale or pro bono policy. I always recommend therapists have a clear policy surrounding sliding scale or pro bono clients. Some things to consider are... Do you require proof of income? What percent will you slide for each income bracket? What circumstances warrant a pro bono client? How many sliding scale/pro bono clients can you afford? Will you re-evaluate need at certain intervals (I recommend every 3-6 months)?

To make this whole process simplified I have a free cheat sheet for you. Click here to download my Sliding Scale Worksheet. This is a worksheet I give members of my Meaningful Documentation program so they can figure out exactly what type of fee feels right and fair for both themselves and their clients. 

Hopefully these tips and the worksheet will help ease any anxiety you may have around money and paperwork. But remember that this is an ongoing thing... it's not something you think about and address and never worry about again (which is why #1-3 are so important). 

What other tips do you have or what strategies do you find useful when fear or anxiety arise? Leave a comment below and share. Let's all be a support for one another... that's the biggest key to overcoming this in the long-term.

3 Ways to Remove Gender Bias from Your Documentation

Ever get confused (or embarrassed to ask) about how to re-work your forms so they reduce stereotypes and stigma? Many of us would like reduce bias but we're either not aware of terms that could be offensive or aren't clear on acceptable alternatives.

Thankfully, Dr. Traci Lowenthal from Creative Insights Counseling reached out to me about this very topic! Traci specializes in working with LGBQIA and Trans populations and has some really easy-to-implement tips for us. 

So click below to check out the video and then feel free to post any questions or comments below. Traci and I will be around to answer questions and engage in the discussion. 

As mentioned in the video, if you'd like to learn more about Traci and her practice or contact her with questions you can check her out at Creative Insights Counseling

Why Your Documentation Is a Mess

I've seen some pretty crazy stuff in client files... like, pretty bad! But you know what's most surprising about finding those things? 

In most cases the therapist had no clue their documentation was a mess.

We're talking like, 99% of the time here. That's not to say they didn't feel a little hesitant. And most of them really disliked doing paperwork. But they had no idea what they were doing made their documentation look so bad.

So I thought I'd share with you some things I've noticed after reviewing hundreds of client files...

The sequence of documentation is super important.

A client's file should tell a clear story. You may have heard that before but let's really look at what this means. 

Most therapists have everything in sections and it's all in a vacuum. The administrative paperwork here. The notes there. Some other random stuff after that. Maybe a treatment plan thrown in the middle.

But what if we put it all together as one story? It's all about looking at the file from intake to where you are right now.

Those initial conversations (your intake and administrative paperwork) led into a treatment plan which led into notes about how you're actually working on that treatment plan. And that leads in to revisions as needed until you have closing paperwork. 

It creates a smooth, easy flow... like calm waves. It's not choppy and chaotic.

Treatment plans, write them out at least a little.

A lot of counselors have a wonderful plan for treatment... in their head. But they never put it down on paper. I talk about some reasons why here in this blog post

Writing it out (even just a couple of sentences) can make a huge impact, for a lot of reasons. It helps keep you on track. It helps you and your client evaluate what's working. And if you bill insurance, it lets them know you're meeting medical necessity guidelines (read more about that here).

Keep your focus on the important things.

When you're writing notes, leave out all the extraneous info (getting people water, the nitty gritty details of a story the client told). Keep it simple and focused. Try keeping each section down to 2-3 sentences. 

Unless you had a crisis session, there really shouldn't be much more than that. Focus on what you did and how your client responded. Note anything that stuck out to you as important or odd. Include the next time you'll see your client. 

And leave it at that.

Review your charts from a storytelling perspective. 

A lot of times what I see in client files doesn't make sense. It takes me a long time to review because the story is disjointed. I need to flip back and forth. Or something is missing and I keep searching to find it.

It takes me a loooooonnnng time to review a messy chart.

However, when a file reads like a story it's so much easier to review. One day flows in to the next and there aren't any big surprises. The interpretation matches the objective info presented and I can clearly see what the therapist is thinking.

I encourage you to go through one of your client's files this week. View it as a story. Does it make sense chronologically? Are there any missing pieces? Do your interpretations make sense with what is presented by the client?

And is it easy to read?

Then head back over here and let us know how it goes! And if you haven't already done so, sign up for my weekly newsletter (and get access to my free Private Practice Paperwork Crash Course) where I send special tips and resources to help you along the documentation journey. 

Cleaning up a mess is much easier with help, so don't be afraid to ask for it! Happy writing :)

3 Ways to Make Your Consent Form Less Boring

Did you know reviewing your consent form with your clients is your first opportunity to start a meaningful conversation about therapy? Seriously, it's way more than just a form. So don't think your first session has to be this super impersonal time reviewing paperwork. 

Let's jump straight into the three ways you can turn your form into a meaningful conversation...

1. Personalize it.

Many therapists think their consent form has to be super formal since it's a legal document. But who says?! Bring your personality to the table right away. If you and your clients are more formal, keep it that way; but if you tend to be more relaxed or playful then add that to your language.

Use language such as "you" and "we" instead of "client" whenever you can. Break up the form so it's not a long box of text. Think through what therapy looks like with you and include as many of those pieces as possible.

Another way to personalize your consent form is to add cultural pieces to it. Make sure the form is relevant to your specific population. Work with kids? Address things like what will happen if a parent asks details about a session. Work with couples? Address what confidentiality will look like if one person asks for records later on. 

It's simply a conversation about how therapy looks, as realistically as you can offer.

2. Create the framework for the relationship. 

This is your chance to put into words the role you play as the counselor. What's expected of you? What's not expected of you? What limitations do you have in your role? What are common misconceptions you encounter that it's important to address?

It's also your opportunity to share what is the client's role. We all know this is a key component of the "success" of the therapeutic relationship... the client's motivation and expectations. However, very few therapists actually discuss with clients what they expect of them.

This means concrete things like arriving to sessions on time and paying for missed sessions without prior cancellation but it also means a lot more. Do you tend to assign homework? Do you expect clients to follow through with things in between sessions? Do you expect clients to talk or participate in other ways? 

These are all key elements to ensuring your clients are aware of the coming journey with you. 

3. Use the form to initiate questions from your clients.

This is the time when you want clients to ask questions about therapy. You want to know what their concerns are. Have they had any previous experiences with counseling and was it positive or negative? What do they expect to happen?

All of these things turn a conversation about a form into what it was originally intended to be- a conversation about the relationship. I like to say that your consent form is simply proof you actually talked with your clients about the limitations and benefits of therapy. 

I hope this helps you to change your thinking a little about what an informed consent form can be. My goal is always to help you create more meaning in your documentation... which coincidentally also makes it easier and more simple. 

If you'd like to learn even more about ways to make you consent form that much better, sign up for my free October training series**. This week is all about informed consent and I've got even more tips for those who sign up. 

Happy writing!

**This training is no longer running, but you can always sign up for my FREE Private Practice Paperwork Crash Course, or check out my Meaningful Documentation Academy for tips, trainings, and more!

When You Need to Think Like an Agency

Most counselors in private practice are accidental small business owners. They love the idea of having a private practice- the flexibility with scheduling, choosing their own clients, and the ability to have their own private office space.

However, they typically don't enjoy many of the business-related tasks with owning a private practice. They rarely think of their practice as a business but rather see themselves as a simple service professional. 

Regardless of the size of your practice, there are times to think like a business, and more specifically, to think like an agency. That's right- sometimes you actually need to think like an agency in order to protect your practice and also improve the work you provide your clients. 

You may be thinking "but I left an agency so I could actually do what I think is better work for my clients!" This is often true and the two ideas are not mutually exclusive. Let me explain...

Agencies have a lot of liability due to the fact that they employ people who are often dealing with complex clinical issues and safety risks. For that reason, they need to create policies and procedures, train employees on these P & P's, and regularly evaluate the effectiveness of the work they're doing. 

Now let's be honest. Some agencies do a really poor job of this. I'm not disputing that fact. However, the principles are excellent. They create a safety net when working in high risk situations and seek to provide guidance for dilemmas before they arise. 

Maybe you're sold on the idea but the thought of implementing sounds like a monumental task. Not so! Here are four things you can do to improve your psychotherapy practice that you can implement in an hour or less:

  1. Write out your sliding scale policy. This is an area that presents a lot of resentment and confusion for counselors in private practice. Many therapists decide on a sliding scale on a whim and few ever outline criteria for determining their scale or a timeline for reevaluating the client's need. Consider the clients who are currently on a sliding scale. Consider your ideal client population. How many sliding scale slots can you reasonably maintain and at what rate? Will you require proof of income/need? For how long will you provide the sliding rate? Answer these questions and bam! You've got a policy. 
  2. Write our your consultation procedure. Ethical dilemmas arise (and usually at the worst possible time). Client needs change and become more complex. In these circumstances it's important to remember you are not an island. There are many other professionals with whom you can consult. Documenting these consultations is important (read more about that here) so write out how you'll do that. Will your consultations be over the phone? Do you have criteria you feel is important to meet before you consult? Do you have certain people with whom you frequently consult? Are you part of an ongoing group for support on clinical issues? Answer these questions and bam! You've got another policy!
  3. Do a review of your client records. I frequently recommend this because it is so valuable. Choose 1-2 records and read through them in entirety. Do you get a good sense of the treatment you're providing? Do you get a good sense of the client's needs? The client's progress? Are there clinically significant things you notice you may be overlooking? This is a great exercise to do when you feel stuck with a client and this is something agencies do on a regular basis to ensure staff are providing good care... as well as keeping up with notes on a regular basis! Which leads me to the last recommendation... 
  4. Decide on a reasonable expectation for getting notes done. In private practice you are your own boss. For some people, that's not always a great thing. I find that one area many counselors behind in is writing notes. It's so easy to decide to just go home and make dinner instead of staying to finish notes. Then you enjoy some family time and go to bed (because you need your rest to write good notes). Then the next day something important comes up and then it's the weekend and your kids have activities planned, and so on and so on. One way to avoid becoming backed up is to create what your business would see as a reasonable expectation for getting notes done (hint: this should be within at least one week of providing the service). Write it down as a policy and stick to it like you're an employee. The key here is that you have the flexibility to make the policy work for you. So consider how that works for you individually and stick to it.

There you have it! Each of those tasks will take less than hour but will greatly improve your business status. They'll also help you to avoid a lot of anxiety-provoking situations and create stability for your practice. 

If you feel like this is still a bit overwhelming, consider booking an individual consultation with me. We can walk through the whole process together and get your documentation handled in no time! 

Leave a comment below if you've tried any of these techniques. What impact did it have on your practice? What lessons did you learn about yourself as a business owner?

Client or Patient? The Language We Use in Documentation

When I was working in an agency in 2009 an interesting shift started happening... the word "consumer" started to replace the word "client." And I really disliked it.

To be honest, I got a little self-righteous about it. "How dare we compare the service we provide to services in some store?" "I am not a consumer at my doctor's office!" "This is so offensive."

I refused to engage in the consumer terminology and kept my well-respected "client" in all my notes. And then one of my coworkers (a fabulous therapist, BTW) mentioned something to me in passing... "I don't understand why we don't use the client's name." 

Truthfully, this thought had never even occurred to me! Rather than writing "the client began to cry when talking about her mother" I could write "Julia began crying when talking about her mother."

Wow... do you notice the difference? It feels so much more personal! 

Hold up, Maelisa, these are legal documents. These are professional notes. Can I really do that?

The answer is yes, you can use whatever language you want!

Perhaps you're more traditional and prefer the word "patient." It conveys a certain professionalism, appropriate personal distance, and is very commonly used. (Side note: it also has the added benefit of easily and recognizably being abbreviated to "Pt" for those of you that prefer as little writing as possible)

Perhaps, like I did, you prefer the word "client." This also conveys an appropriate distance and reflection of the relationship while also valuing that therapy is different from other "medical" treatments. 

Perhaps *gasp* you actually prefer the word "consumer." Well, I can't blame you... our clients truly are consumers of a service. We are reminded of that every time issues arise with payment or dissatisfaction. 

Perhaps you prefer the word "member." This is common in insurance circles. While it may currently have a negative connotation for many, the idea behind being an active "member" is really quite noble. It conveys some investment in the service provided. 

Lastly, perhaps you prefer to use the person's name, like my friend and co-worker. That conveys a personal meaning to the notes and you know what, it gets the job done just as well as any other term we create for a sense of professional distance.

The actual phrasing doesn't really matter. What matters is the content, the meaning behind it, the story that unfolds note after note. 

I love when I review a client's file (for another therapist, not a client of my own) and I can picture exactly what it's like to be in the room with that person. I am able to read about their subtleties, personality and nuances. That's what matters.  

So, do what feels comfortable for you. Do what is meaningful to you. Write your client's story of treatment with you. And don't worry about it any more than that. 

What terminology do you use in your documentation and how come? Have you struggled with this topic? Leave a comment below. I'd love to hear about it!