A Therapist's #1 Secret Productivity Killer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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. 

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!

10 Tips for Documenting in Crisis

In the wake of the Orlando shooting, I noticed questions popping up about how to obtain consent and document therapy when providing crisis services. My goal is to support you in the awesome clinical work you provide so I've compiled a list of tips for how to proceed quickly so you can get in there and be a support for others.

Two common ways in which this occurs is that you'll either volunteer services through an agency or organization of some sort, or you'll offer to provide services in your office. Since these situations present different responsibilities on your end, I've separated the tips out. 

If you're providing services through a crisis center/agency/other organization:

  1. Ask. Make sure you check in with whomever is in charge to see what is expected of you. Is there a brief form you should have people fill out? Where should you write a note documenting whom you saw and where does that note go?
  2. Make suggestions. It's very common that systems and procedures are not set up in crisis situations. This is your opportunity to provide a nice suggestion. Offer to use your own note template or informed consent language. Offer to meet with other counselors and determine a protocol. Take a leadership position if necessary, because people are counting on you to be the professional.
  3. Document anyway. In some situations you may be encouraged to be more lax. While I agree this isn't the time to split hairs, crisis situations don't give you a free for all. You're still a professional with ethical guidelines so even if someone in charge wants to give you a pass, write up a note anyway.
  4. Be timely. No matter how chaotic things may be, do any required documentation immediately. It is too easy to get caught up in the whirlwind around you and then forget what happened with the 9th person you saw that day. Be responsible and take the time to get notes done. 
  5. Check in re: follow up. Make sure you have a clear sense of what will happen after you meet with someone. Is this a one-time debrief or an opportunity to connect with more ongoing counseling? If you feel someone needs additional services, where do you recommend they go? Set yourself, and the people you will meet, up for success rather than disappointment or abandonment. 

If you're providing services in your office:

  1. Reduce and reuse. Go through your intake and consent documents and identify what is the bare minimum information you need to review with someone before proceeding. Crisis likely isn't the time to go through your social media or texting policy, but you do still want to establish some boundaries and expectations.
  2. Explain yourself. When you choose to do the minimum necessary, it's important to explain why. Use your progress notes to explain why you chose to leave out certain things. This is your chance to provide your rationale.
  3. Be timely. Do these notes right away. When emotions are high it is very easy to forget specifics, even though you think there's no way you'd be able to forget such details. Even if you're behind on notes for other clients, do these crisis notes NOW.
  4. Be clear about follow up. Clearly identify with the client and clearly outline in your notes what the plan is for follow up. Is this a time-limited or session-limited series you're providing? Are you meeting with someone in the absence of their own therapist and planning to provide a connection at a later time? Or is this potentially a new client for you? Additionally, you'll want to be clear about who the client should contact (and how) should they feel the need outside of your session.
  5. Revisit when it's appropriate. If you end up seeing this client more long-term, it doesn't mean you get a "pass" for reviewing all that stuff you originally omitted in the beginning. After a few sessions, revisit those things (like your cancellation policy, etc.) that may not have seemed so crucial in the crisis moment. No need to ruin a good therapeutic relationship because you both weren't on the same page two months later.

Of course, crises are as wide and varied as the people involved in them, but these tips can help you have some order and direction in what is often a chaotic situation. 

What other tips do you have for documenting in a crisis situation? Share in the comments below and let us know what has worked well for you... or even what didn't work well and you'd never do again!

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!

3 Big Problems Therapists Had in 2014

You know how your clients often get stuck coming in and talking about the same problem session after session? You review with them strategies you've previously discussed or you process why the same patterns seem to continue across relationships and circumstances. And, while every person is unique, you begin to see common themes emerge.

Well, in 2014 I started QA Prep because I noticed therapists asking lots of questions related to clinical documentation... and I started to see patterns emerge. The same questions, over and over again. And I thought, "what if I developed resources for therapists so they didn't have to search all over for answers?" I opened shop in April and spent a lot of time answering emails, responding to questions in Facebook groups and problem-solving over free consultation calls... and here are the main things therapists had problems with in 2014:

Time Management

Did you know the majority, yes the vast majority, of your colleagues struggle to keep up with their paperwork? If this is a struggle for you, you are not alone! This is one of the most common and one of the most destructive problems I see. When therapists think documentation is boring and meaningless, they avoid it or do sloppy work. And once you're behind by one day, it's easy to push things back further... and before you know it, you're a whole month behind on documentation. And then the paperwork to be completed looks like a huge mountain to scale.

The game of catch-up, fall behind, catch-up, etc. becomes a vicious cycle and creates a lot of resentment toward documentation. 

The key is really to be honest with yourself and create a realistic plan. Don't do what your previous supervisor told you worked for them or what the therapist down the hall is doing. Do what works for you! Some people choose one day per week to do all their paperwork, some do notes for every individual in the 10 minutes between sessions, some do notes for an hour at the end of the day. These are all possible strategies to try. The "best way to do paperwork" is whatever works to actually get it done. I would recommend at least creating a weekly plan so that by the end of the week you know everything is complete and don't have to catch up later. 

Insurance

I consistently get a lot of questions about insurance, relating to reviews by the insurance company, how to write notes and treatment plans for insurance, and what CPT codes to use for different sessions. Honestly, the CPT code questions are the most common and also the easiest to answer! Here are the top three...

Q: What code do I use for couples counseling?

A: For insurance and coding purposes there is no such thing as couple's therapy, there is family therapy. Use the family therapy code, 90847, when doing couple work and clearly identify why the marriage counseling is assisting the individual client with his/her mental health needs. This still requires the individual to whom you are billing insurance to have a diagnosis. 

Q: Does insurance cover teletherapy and what code do I use?

A: The answer is, it depends. Some states have required insurance companies to reimburse for telehealth services but some have not. Furthermore, the requirement does not set a standard for payment, meaning the insurance company may reimburse teletherapy at a different rate from your in person sessions. The key is to know whether or not your state is included in this list and to check your individual contract with the insurance company. If you are able to provide teletherapy, use the regular therapy codes with a "GT Modifier."

Q: Does insurance cover (insert service or code here)?

A: Again, the answer is, it depends. Every contract with an insurance company is unique, meaning the therapist in Suite A may be contracted to bill seven different codes/services at a specific rate and the therapist in Suite B may be contracted with the same insurance company to bill nine different codes/services at a different rate! This means the answer to any question about what you can bill lies in your contract. Do not rely on your colleague's experience in this area, make sure to look at your individual agreement. As a side note, this also means that yes, your rates are negotiable... if you want them to be!

Staying Up to Date

Lastly, another concern that is common is figuring out how the heck to stay up to date. Many therapists feel pretty competent in their documentation but after 15+ years in practice they are unsure whether or not they're up to date. Documentation is not a common topic to discuss, especially among seasoned clinicians, and it's easy to start feeling as though you may be missing something. 

The obvious is answer to this dilemma is taking continuing education classes, especially in areas such as ethics, HIPAA, and clinical documentation. Also, join your local and/or state professional association. Their job is to stay abreast of changes in mental health and update their members accordingly. Interestingly, I first heard about the 2013 changes to CPT codes from the California Psychological Association, not my agency or connections while working in quality assurance!

However, another great way to stay up to date is through consultation with colleagues. Choose a trusted colleague and discuss one to two cases together and how you do your paperwork for that case. Better yet, choose a colleague who has recently attained their license and then another colleague who has 15+ years experience. You can also review 1-2 of your client files ahead of time and come with questions. It's a great learning experience and you'll likely gain a few helpful tips from one another!

If you're not sure how to get started with a consultation group, sign up for my monthly newsletter (and get immediate access to my free Paperwork Crash Course), where I review tips on this and other ways to improve documentation. I take a totally judgement-free approach in all my material and I'm always creating new programs for therapists who want rock solid documentation. 

Share in the comments below any other struggles you think are common and we'll problem-solve together!

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.

The Mountain of Paperwork in Community Mental Health

Mountain of Paperwork

Clinical documentation- mention it to most therapists working in community mental health and they will cringe. Along with that word comes mental images of being flooded with redundant paperwork, staying late to write progress notes (or worse yet, working from home), and having supervisors identify endless corrections needed. Few clinicians or supervisors will tell you they enjoy this aspect of their job. Fewer still will tell you they felt prepared for the demands of government-contracted requirements through their training in graduate school. Yet, ask any therapist with a client who has attempted suicide and they will tell you (perhaps begrudgingly) this is one of the most important aspects of their work. 

Clinical documentation is invaluable when we need it most. Progress notes document our efforts to contact clients exhibiting high risk behaviors. Consultation notes document  standard of practice and a rationale for our actions when “grey areas” appear. Mental status exams and assessments document the client’s history of symptoms and provide a course for treatment. Clinical documentation is a necessary tool for therapists working in the revolving door of community mental health. 

However, many therapists find the paperwork difficult to maintain. They don’t see the connection between the clinical work and the forms they’re required to complete. They feel drained and overwhelmed by the daily paperwork requirements. 

If you are a clinician working in community mental health and find yourself becoming overloaded with paperwork, try following some of these steps:

  • Prioritize your paperwork according to it's importance.
  • Talk with your coworkers to see what tips they find useful.
  • Do your best to keep interactions with your coworkers positive.
  • Decide from the beginning that you will NOT fall into the trap of “fudging” the time you bill by 10-20 minutes here and there.
  • Be honest with yourself regarding your strengths and weaknesses.
  • Engage in self-care.
  • Stay connected with your colleagues.

Make sure you talk with your supervisor from the beginning about your struggles to get the support you need. Seek out extra training and consultation. Your agency may offer refresher trainings or, if you’re in the L.A. area, you can check out the upcoming workshop I’m doing on documentation (trust me, I try to make it as fun as possible!). You can also sign up for the QA Prep Newsletter (and get access to my free paperwork crash course) to get tips on making documentation easier and more relatable. 

Don’t be afraid to evaluate different job options if you find you’re a round peg trying to fit into a square hole. When you’re less stressed, you’re providing better care for your clients. Keep the focus on being the best therapist you can be- in all aspects of your work and don't be afraid to ask for help when you need it. Happy writing, everyone!!

What is Medical Necessity and why do I care?

Medical necessity is a term used by insurance companies to determine if a client needs services, and what services are appropriate. If a client “meets medical necessity” then services are approved! If not, you get that dreaded denial letter. Each insurance company has their own definition of medical necessity, but there are usually three main components:

  • Diagnosis
  • Impairment
  • Treatment Plan

Diagnosis- Most insurance companies want to see a DSM diagnosis for clients to quality for treatment. It is not enough to randomly list a diagnosis (and also not ethical). You need to identify the client’s symptoms to show they meet the DSM criteria.

Impairment- People can live with a diagnosis and not really have an impairment. But, when symptoms start affecting a person’s work or personal life, they need treatment. An impairment is an area of life that is negatively impacted by the client’s diagnosis. Example: The client is depressed and has low motivation and difficulty concentrating which impacts their ability to complete tasks at work and they are now on probation.

Treatment Plan- We’ve identified that the client needs help. Now, what are we going to do about it? It’s the therapist’s job to show the client and the insurance company how they plan to help. Will you introduce certain topics or coping skills, will you use an evidence-based practice, etc. Check with the client’s insurance company, because you may need to identify how many sessions you think this will take.

Medical necessity is a great way to conceptualize your client’s needs and how you can use your expertise to help. If you’re billing to an insurance company, it’s a requirement. If you still need help, sign up for Maelisa’s newsletter and check out QA Prep’s Facebook page for more helpful tips.