My Supervisee Isn't Writing Progress Notes! What Can I Do?

This is a supervisor’s worst nightmare, but it’s also a fairly common scenario: You find out (usually inadvertently) that a clinician you supervise hasn’t been writing therapy notes.

You want to take immediate action, but what options do you have? Your options depend on a few important things, such as:

  • Is the supervisee licensed or working under your license?

  • Are you supervising this person while employed at an agency, or is this a private practice setting?

  • Is the supervisee an independent contractor or an employee?

Important Side Note: The regulations for each of these vary greatly depending on both your state AND your profession (e.g. psychologist versus professional counselor) so not all of these options will apply to everyone.

Let’s look at this scenario from a couple viewpoints and divide them into Independent Contractors and Employees so we can look a little bit deeper…

Options Based on Employment Status

Important Side Note #2: I am NOT an employment attorney and am giving general advice based on what is common in most mental health practices. You should definitely consult an employment attorney in your state about this topic if you’re dealing with this scenario.

Independent Contractors & Therapy Notes

If the therapist who is behind on notes is an independent contractor, rather than an employee, one option is to make sure that your contract with this person states a complete progress note is part of the service provided. Therefore, no payment is made until notes are complete. 

This doesn’t totally solve the problem because the person could still choose not to write notes and not to get paid (yes, I’ve seen this happen), so you’ll also want to identify in your contract:

  1. Who is in charge of keeping and maintaining client records and

  2. What timeframe is acceptable for completing notes

This gives you options to determine whether or not you want to continue hiring this person, and grounds for making such a decision.

For example, you may not be as concerned if the therapist is fully licensed and maintaining their own records. While this is certainly not ethical practice, your personal liability may be much lower in this scenario.

Let’s play out a somewhat common scenario where you likely have very little (or no) liability:

Perhaps you are an LPCC with a private practice and you have a psychologist who is an independent contractor and provides psychological testing. You have an agreement that they maintain all their own records but since you are referring them clients, your clients typically provide a Release of Information so that you can obtain a copy of the final testing report. In this scenario, you likely have little to no liability if the psychologist isn’t doing their job and writing notes. You might choose to stop working with and referring to this person, but that’s aside from a liability standpoint.

Let’s play out a somewhat common scenario where you likely DO have a good amount of liability:

Perhaps you are an LPCC with a private practice and you are supervising an unlicensed clinician who pays you to sign off on their hours (FYI- this is where circumstances get state and profession specific). You meet with them regularly but you honestly didn’t think to talk about progress notes and this supervisee never asked. Then one of their clients requests a copy of their records and the supervisee confesses there are no therapy records because the supervisee hasn’t been writing progress notes. This scenario can play out many different ways at this point but many clinicians would immediately point to the supervisor and ask why records and progress notes were not discussed previously.

Employees & Therapy Notes

In some ways, you likely have more power to manage this situation if someone is an employee.

You can choose everything about your policies and procedures and then enforce them accordingly. That means you identify what constitutes a progress note, how long people have to write therapy notes, what progress note template they use, what is included in a progress note or process note, where the clinician writes therapy notes, etc.

However, you typically have to continue paying them for catch up time writing progress notes if they are an employee (since most state laws will require payment for time while someone is working).

At this point, your only decision is how to enforce your policy and what consequences this supervisee will experience.

Ideally, your policies and procedures will spell out exactly what should happen in this scenario because, guess what? It WILL happen to you at some point.

So the key progress notes policies and procedures you want to have in place are:

  • Have a clear policy (and/or IC contract) about when notes are due.

    I know you want me to tell you what is acceptable here. ;)

    I recommend a policy that notes are due either 24 or 48 hours after a service is provided.

  • Have a clear policy about what happens when someone falls xx number of days behind in notes.

    I’ll offer another recommendation here: An action plan needs to happen when someone is a week or more behind in notes. This is a tipping point for many clinicians and allowing people to get more behind negatively impacts EVERYONE involved.

  • Have a clear policy about what is included in a progress note and which scenarios require progress notes (e.g. phone calls and voice mails).

  • Have a clear policy regarding how often supervisors review notes and/or check that notes are completed, regardless of whether they supervise people who are licensed or unlicensed.

    Yes, supervisors need policies, too!

  • If you are working with Independent Contractors, identify who owns and maintains the mental health records.

  • Document any training you provide on writing progress notes, record keeping, etc.

  • Document ongoing conversations about reviewing progress notes, improving progress notes, being behind in progress notes, etc.

  • If you discover a training need (e.g. a clinician is behind in writing therapy notes) document the plan for that clinician, including a due date and what will happen if therapy notes are not completed by the due date.

I find the difficulty here is NOT in the policies and procedures themselves. It is in the enforcement of the policies and procedures…

Yes, that means the problem really lies with the fact that the supervisor didn’t know what was going on and found out too late.

#leadershipequalstakingresponsibility

Again, this is super common and the situation sucks for everyone involved. But as a supervisor, your role is to learn from this and improve things for everyone moving forward.

Here’s what I recommend if you discover a supervisee is behind on writing therapy notes:

Have a very honest conversation with the clinician about their struggles. Many therapists have so much shame around this topic. Offering support and encouragement can often be the catalyst for change, because no one wants to be so behind.

So many therapists feel powerless in this situation. Focus on empowering this clinician with resources and TIME to get caught up.

>> But also provide extremely clear and concrete boundaries and progress markers… and then FOLLOW UP. 

What Are The Potential Consequences For Not Writing Progress Notes?

The potential consequences for the supervisor are mostly ethical related and based on whether or not this is reported (either by someone in your agency or practice, or by a client who requests records which end up not being available). So, if no one ever needs anything there could potentially be no consequence at all. If the Board found out, then consequences likely range from a reprimand to temporary license suspension (although that’s totally dependent on the Board).

The potential consequences for your practice or agency include fines or penalties (if a client requested their records and none were available), loss of funds (if there were an audit, depending on your current revenue streams and the requirements thereof), and/or a potential case with the supervisor in question.

The potential consequences for the supervisee are also mostly ethical related and based on whether or not this is reported and if so, to whom… and then, what action (if any) that entity chooses to take.

>> However, this is where things can get a little tricky because although most of us would probably agree that even an unlicensed person should know they need to write progress notes, this kind of thing can sort of be turned around in some cases. Meaning, the supervisee may turn around and have an argument that they were not clear about policies, that there were no policies at all, that they received no training and/or supervision, etc. 

This is why your policies and procedures, as well as documenting that you have reviewed these with people, are paramount in this situation.

You know what else is paramount? NEVER assuming that ANYONE has been trained in documentation or feels comfortable with documentation.

The sad reality is that dozens of therapists admit to me every year that a supervisor has shamed them for their progress notes at some point in their career. If you are a clinical supervisor and reading this, please don’t be that supervisor!

Instead, provide expectations, boundaries, and guidance.

If you’re a clinical supervisor and feel ill-equipped to offer guidance on documentation (another common scenario I see!), then check out my trainings and pass this info on to your supervisees.

Trust me, they’ll be relieved if you bring up the topic, and even admit you have apprehension about it yourself!

One Quick Tip for Better Paperwork

No, really!

How many times have we seen those ads at the bottom of a page or on Facebook? The one secret that will make the weight melt off, the one thing you shouldn’t eat, the one trick for cutting bills in half…yeah, right.

But this isn’t a trick or a secret.

This is a legitimately quick tip that will ease your mind if you’ve ever worried about your paperwork being reviewed in an audit, or by a lawyer or even your client.

If that sounds like you, this is going to help you feel a lot better about your paperwork.

>> One of the most important things you can do, that’s often overlooked by therapists, is document getting informed consent right from at the beginning of your work with someone.

I’m not talking about getting your intake form signed, because most people are really good about that. Even if you’re not reviewing the form with people, you probably have it signed.

What I’m talking about is taking the next step to CYA.

First, make sure you really are reviewing the intake form! You can’t have informed consent if you’re not…informing people, right? Reviewing the form gives you a chance to highlight important topics like your cancellation policy or limits to confidentiality, the things that can potentially become problems down the road, and answer any questions clients might have.

I do want to remind you that informed consent is a fluid process, not a one-time thing you do and never address again.

So if you miss something it’s not a big deal, you can just go over it another time.

But it’s not good enough to just go over consent and have someone sign a form. You want to document it in your intake note.

I know. You’re thinking I’m documentation obsessed. You’re not wrong, but hear me out because this will take so little time and has fantastic payoff.

When you write your very first progress note from your very first session, you want to make sure you include all the regular progress note info, and you also want to write something like, ‘reviewed intake packet with client.’

Write down specifics like:

  • Reviewed limits to confidentiality and potential benefits and drawbacks fo treatment.

  • Discussed fees and cancellation policy.

  • (If needed) Reviewed limits to confidentiality between adolescents and parents.

    And finally …

  • “…and obtained consent for treatment.

Of course you might have other things in there that are important to note because it will depend on your practice, the client, and the session. But MAKE SURE you document that you did review the forms with your clients AND you got their consent to treat them.

It’s just a few extra lines in your note, but it shows clearly that you started treatment exactly the way you’re supposed to, and it will give you extra confidence in your paperwork from day one.

If you’re looking for other tips on making your paperwork better, check out my free crash course or head on over to the Meaningful Documentation Academy for full access to all the best information and trainings to help you love your paperwork.

Insurance Records Requests: Rules to Remember

Here’s a question I get all the time:

Can insurance companies request my therapy records?

Sometimes it’s asked a different way:

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

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

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

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

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

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

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

  • Insurance companies can request therapy records

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

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

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

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

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

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

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

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

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

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

What does accurate diagnosis mean?

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

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

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

Progress Notes and Online Text Therapy Platforms: Doing It Right

These days therapy isn’t necessarily hour-long sessions with a client in your office.

That’s SO 2014. Now we have video therapy and text therapy through apps, which are an amazing tool for you and your clients, and introduce a few new considerations for therapists, particularly around progress notes.

First of all, let’s define ‘text therapy.’ It’s a pretty simple definition but we always want to be clear when we’re talking documentation, right?

Text therapy is providing therapy through any format where texting or online chatting are your main form of communication. This can happen through apps like TalkSpace, BetterHelp, and more. Sometimes you’ll combine video, phone, and texting, and the same considerations would apply to those combos.

Personally I LOVE these formats!

Still, there are a few big points to think through when you’re either considering offering counseling through these platforms or already are offering services through these platforms.

Assessment, support, and information

First, you want to assess your level of risk and figure out how comfortable you are with it. Some people love trying new things and find it easy to think through all the issues and come to a decision. Some have a harder time, and might not love the idea of being dependent on someone else (the app) for record-keeping, etc.

Second, you want to make sure you have a solid support network of other therapists to consult. If you don’t have that network in place, please get working on that before you engage in these new platforms. If you’ve already started, get that network together now.

Third, you’ll need to be aware that you probably won’t have a lot of access to the client information you’re used to seeing. These platforms are great for anonymity, which can be a really awesome tool for your clients. Some clients will feel more comfortable sharing and being honest because they know you have limited info. Some clients may never have considered therapy without the choice to remain anonymous.

Anonymity can be excellent for the therapy process, but it does come with some issues for you to be thinking about:

  1. You want and need basic client information, like name, phone number, and address.
    Why? Because sometimes you get cut-off mid phone call, or the app might stop working, and you’ll need to be able to communicate with your clients if that happens. A client might start exhibiting suicidal ideation or you may realize they’re in danger, and you’ll need an address. Now plenty of your clients will be happy to give you the basics, so just ask them.
    
And then, if needed, keep asking. 

    I’m not saying harass them about it, but as the information is relevant, make a point to ask them again if they’ll share those three things.

  2. Who keeps the records?
    You’ll get to the root of the problem and get the answer you need by simply asking your platform provider what happens in case of a records request. For your own peace of mind and for your clients’ sake, you’ll need to know whose responsibility it is get the clients their records and what is revealed in the process. 
If the app says, ‘Well we don’t have anything to give them,” then you know they aren’t keeping records at all, and you’ll need to keep a full record to CYA. On the other hand, if they say they can hand over entire transcripts of conversations, then you know that what’s being said isn’t completely private, and you need to pass that information on to clients.

And then there’s the notes question.
Where do you write progress notes? How?


Well, you’ll need to know where to access the data you do have on clients. Maybe you’ll keep your own record on the side, or maybe you’ll feel more comfortable keeping a full record. It depends what you have access to through the app.

Either way, keep your notes wherever you have access to the rest of a client’s info. You’ll need access to them in order to protect your clients and yourself, to write reports if a client requests them, etc.

And of course, you need to write notes for EVERY session. If you have specific sessions by chat where you are 100% focused on the client for an hour, write your progress notes as usual after each session.

If you’re texting back and forth all the time, instead you’ll want to do daily or weekly summary notes. So maybe you spend ten minutes talking on Monday, and five on Wednesday, and then a few minutes Thursday, Friday, and Saturday, and you write a weekly progress note.

Maybe you spend lots of time on texting in between video sessions, in which case you’ll need a regular note for the video session and a summary of what’s going on in the texts. This way you’ll be able to refer back to what you’re working through, what techniques you’ve used, and what progress a client is making, even if it’s not happening in a traditional way.

There you have it: If you’re considering starting text therapy, think all of this through ahead of time. If you’re already doing it, make sure the processes you have in place cover everything.

Looking for more information on notes? Check out my Therapy Notes FAQ or the Comprehensive Note Writing Guide for Therapists

And if you want something that covers mental health paperwork in general, sign up for the Private Practice Paperwork Crash Course.

Avoid Fraud When You Diagnose

Here’s a common scenario: A new client comes in, obviously in need of your services. You want them to be able to use insurance because you know how important therapy is and want to make sure they get what they need. So you diagnose them with something —anything— to make it happen. 

You think you’ve done them a favor, but what you’re really doing is committing FRAUD.

It happens every day, and most therapist don’t even realize they’re breaking the law. I’m here to help you avoid fraud! That’s why I want to talk about the major mistakes people make when giving a diagnosis for insurance. 

Watch the video to find out more or keep reading below…

The first thing to remember is that any diagnosis you give, for any reason, must be real and accurate. So get out that DSM and make sure!

Even when I was diagnosing people every day as part of an agency job, I always double-checked the criteria for every diagnosis, every time. Why? Because even when we think we know a diagnosis inside and out, the DSM offers crucial guidance to getting it right. And unless you have a photographic memory, you probably don’t remember every single component of every diagnosis. 

The two big mistakes people make in a diagnosis that often lead to fraud are over-diagnosing and under-diagnosing. 

Let’s look at a common diagnosis to see how this works in practice: Adjustment Disorder.

Under-diagnosing


In under-diagnosing a client, you’re probably forgetting the ‘rule of severity.’ One of the main criteria for adjustment disorder is that if someone meets the criteria for another, ‘more significant’ disorder, you *must* diagnose them with the other disorder.

For instance, you may have a new client who fits the criteria for Bipolar Disorder and sought you out while in the middle of a Major Depressive Episode. If that’s the case, you are not allowed either legally OR ethically to diagnose them with Adjustment Disorder.

Sometimes we therapists worry about documenting something like Bipolar Disorder, concerned the diagnosis might do harm to our client.

In those cases, our job is to remember how important it is for our clients to have accurate medical records for their own health, as well as for us to be doing the best job possible providing the services our clients need. We fail at both of those if we don’t diagnose properly.

Over-Diagnosing


Over-diagnosing looks like this common scenario: a client comes to you in major distress, even though they don’t meet the criteria for any specific disorder. They could be experiencing a major transition or experiencing stress related to job loss, a major move, etc. In cases like this many therapists will ‘fudge’ a diagnosis; after all, everyone meets the criteria for adjustment disorder, right?

Well as much as I like fudge to eat, it’s a bad idea for diagnoses!

You don’t want to give someone a mental health diagnosis if they don’t actually meet the criteria, because you have no idea how it might impact them in the future. It’s just as bad as under-diagnosing to avoid what you might consider a ‘harmful’ diagnosis.  

Basically, therapists should never (ever!) give a diagnosis to a client unless they meet the criteria.

If you want to keep the insurance companies happy, clients happy, and yourself protected, diagnosis is just one part of what you need to consider for clients who use insurance. Click here to check out everything you need to know about insurance and medical necessity. 

Documenting Text Messages and Emails

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

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

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

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

Think of texts and emails like voicemail.

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

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

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

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

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

That’s it! Easy!!

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

Summarize, summarize, summarize

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

Don’t overwhelm yourself!

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

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

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

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

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

Let us know in the comments below:

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

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

Writing Court Letters in Private Practice

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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


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

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

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

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

Let’s dig into each of these issues…

The Ethics of Dual Relationships and Scope of Practice

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

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

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

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

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

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

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

Are there exceptions to these guidelines? Always!

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

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

So what do we do about writing court letters?

Keep writing them!

(Or don’t… more on that in a minute)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to check it out.

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

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

Do Therapists Really Get Disciplined for Failing to Take Notes?

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

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

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

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

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

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

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

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

Yes!

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

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

  1. The clinician failed to obtain proper informed consent.

  2. The clinician failed to maintain adequate records.

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

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

The clinician failed to obtain proper informed consent.

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

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

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

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

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

The clinician failed to maintain adequate records.

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

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

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

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

What can you do to avoid these potential problems?

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

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

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

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

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

Therapy Notes: Your FAQ's Answered

>> Dealing with notes from months ago.

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

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

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

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

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

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

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

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

  2. How Much To Include In Progress Notes

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

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

  3. Worries About Insurance Audits of Therapy Notes

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

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

  4. HIPAA & Progress Notes

    1. What are psychotherapy notes based on HIPAA?

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

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

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

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

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

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

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

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

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

 

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

Sometimes this happens. And it sucks. 

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

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

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

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

 

2. How Much To Include In Progress Notes

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

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

I recommend asking yourself some key questions while writing:

  • What was the theme of our session?

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

  • What seemed important to my client during our session?

  • What do I want to follow up on? 

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

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

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

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

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

 

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

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

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

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

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

 

3. Worries About Insurance Audits of Counseling Notes

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

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

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

  1. Progress made

  2. Ongoing need

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

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

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

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

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

  • How is therapy improving their health or relationships?

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

 

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

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

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

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

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

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

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

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

 

4. HIPAA & Psychotherapy Notes

"What are psychotherapy notes based on HIPAA?"

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

 

Want to see some actual examples of progress notes?

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

Documentation Consultations: Policies, Forms and HIPAA

We're back with our consultation series where I'm recording consultations I conducted with real and practicing therapists across the country. This time I'm talking with Sandy Demopoulos, a licensed clinical social worker in New York. 

We talk about a lot of things in this interview (which is why it goes a bit longer), but go in depth regarding the following:

  • How the HIPAA Notice of Privacy Practices applies to mental health clinicians

  • How to determine what level of detail to include in your policies/forms

  • What to review with clients who may be court-ordered or working with other agencies

  • Dealing with payment issues, credit card maintenance and collections

  • What to consider with social media policies

I also do something in this interview I haven't done before... I review my own Services Agreement! It's the one that is included in my Therapist's Perfect Paperwork Packet and we go through the various sections that are included. 

Please excuse the phone ringing a couple times in this video... I promise, all the info you'll receive is worth ignoring it for a few seconds!

Resources we discussed in this video:

To check out the Model Notice of Privacy Practices available for free at hhs.gov, click here. Remember to scroll down a bit and select one of the options under the section titled "NPP Provider Files."

To get CE credits for watching the webinar Roy Huggins and I did on the informed consent process, click here

To check out IvyPay, a service that safely collects and maintains credit card information for clients (particularly if you don't use an EHR that provides this service), click here

If you've decided you don't want to deal with creating your own forms at all, then click here to check out my done for you paperwork packet

If you want to check out the more extensive (and free) social media policy available from Dr. Keely Kolmes, click here

If your forms are pretty much set in place but you don't have a court policy, click here to get a great copy from Therapist Court Prep.

Lastly, if you want to check out Counsol, the electronic health record Sandy and I are both using, click here. Note that if you choose to sign up with Counsol as a result of clicking my link, I will receive a discount on my service.

Enter your info below if you'd like to receive weekly email tips on documentation and check out my FREE Paperwork Crash Course!

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Paperwork Tips from Experienced Therapists

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

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

Use an Electronic Health Record (EHR)

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

Stay On Top Of Notes with Productivity Hacks

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

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

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

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

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

Document the Little Things

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

Use Your Experience as a Resource

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

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

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

Communicate With Your Clients

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

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

Lastly, Amber Hawley of Fremont Counseling Services has one last tip for you... sign up for my Webinar CE Club! (Edit: the Webinar CE Club is no longer, but you still get access to all my ote writing tips and trainings in the Meaningful Documentation Academy!) I swear, I didn't tell her to say that ;) But it does highlight the importance of staying connected with colleagues and making room for this type of discussion so that you can always have the best resources. 

Feel free to share your tips below in the comments!

Credit Cards: Your Questions Answered

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Feel free to post any questions below!

Prepare Your Records for Release

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

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

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

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

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

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

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

Think about your client viewing their notes

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

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

Think about and discuss your policies

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

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

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

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

Have the insurance conversation

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

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

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

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

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

Resources for Online Counseling and Paperwork

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

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

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

Online Options for Counselors

Video therapy using your own practice

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

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

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

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

Contractor for an app based video service

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

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

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

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

Contractor for a text-based therapy service

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

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

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

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

What to Consider

Ethics

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

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

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

Practicality

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

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

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

How and What to  Document  

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

Informed Consent  

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

  • What happens if the client's needs increase beyond what can be ethically provided online

  • Procedures to follow in case of poor connectivity or internet outage

  • Procedures you'll follow if you feel your client is in any danger

  • Communication outside of session

  • Expectations for online interaction and the importance of checking in regularly

Emergency Procedures

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

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

Resources You Must Follow

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

Person-Centered Tech

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

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

Online Counselling Podcast

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

Telemental Health Institute

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

Now what to do...

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

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

The Comprehensive Note Writing Guide for Therapists

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

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

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

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

Let's dive in...

Questions to ask yourself when writing notes

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

Consider who may read your notes

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

Create your own notes template with check boxes

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

Choose a notes template that works for you

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

Figure out how long your notes need to be

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

Review your notes to see how you're doing

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

Write notes that make insurance companies happy

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

Identify ways to save time on notes

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

Catch up on notes if you've gotten behind

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

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

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

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

**The Counselor's Guide to Writing Notes is now included with membership to the Meaningful Documentation Academy.

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!