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.

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?

More of My Favorite Intake Assessment Questions

You may have already read about My 4 Favorite Assessment Questions but let's get into some more! In this video I'm sharing four more questions I recommend you ask your clients during the intake process.

These questions will help you get the necessary historical data to treat them best but also help you make a connection more easily.

Still have questions about the intake assessment process and questions to ask clients? Then check out this blog post on Assessment Dilemmas and FAQ's to get some tips on how to simplify the intake process. 

Let us know in the comments below what your favorite questions are to build rapport with clients and get the information you need to provide them the best therapy possible. 

Better, Faster Treatment Plans

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

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

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

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

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

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

Here are some benefits of writing treatment plans with clients:

  • You'll be able to use your client's own words to describe their concerns, needs and goals

  • You're able to receive immediate feedback on what they want out of therapy or how they view the counseling process

  • You can share with them what your involvement is in the therapeutic process

So, if you've never tried doing this before and treatment plans are a hassle for you, try it out!

Let us know what you think in the comments below.

Step-by-Step Intake Progress Note

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

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

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

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

  • Limits to confidentiality

  • Potential benefits and drawbacks to treatment

  • Consent for treatment

  • Attendance policy

  • Communication outside of session

  • Reason for seeking treatment

  • Assessment of symptoms

  • Assessment of biopsychosocial data

  • Plan for treatment

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

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

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

Want to see an example progress note?

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

Data: 

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

Assessment:

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

Plan: 

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

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

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

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

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

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

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

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

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

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

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Assessment Dilemmas and FAQ's

assessment dilemmas.jpg

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

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

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

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

My assessment process

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

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

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

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

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

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

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

Your FAQ's about assessment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Review of Notes and Electronic Health Records for Therapists

It's about time I did a review of some Electronic Health Records (EHRs). I get questions ALL THE TIME from therapists who want to know...

  • What EHR do you recommend?

  • What is your favorite EHR for notes?

  • How do you set up paperwork inside your EHR?

Today, I am answering those questions by providing an overview of eight different EHRs. There are many more EHRs available and I simply haven't been able to check them all out. However, all of these below are ones that I have either tested and played around with or received a virtual tour from staff at the EHR (super thankful for all their time answering my questions and showing me around!). 

Important note before you dig in:

I am not personally endorsing any of these EHRs for your practice. I strongly believe that with all things documentation, you need to use what works best for you and that will often be different from what works best for other people (including me). So, please do use this as a resource to get an idea of what you might like and then try it out for yourself.

Although I do receive an affiliate commission for some of them, I am 100% honest about what I like and don't like about each EHR and let the EHRs know that up front, as well. I know you certainly don't want me holding back ;) 

To be as fair as possible, my reviews of EHRs for therapists are listed in alphabetical order:

Counsol

Okay, let's get this out of the way- yes, this is the EHR I am currently using. Why did I choose it? Because it offers integrated video sessions for online counseling and because it offers a client journaling feature, along with all the other typical EHR goodies (billing, scheduling, notes, text or email reminders, client portal, etc.). I will be honest though, and say that I haven't used these features nearly as much as I originally anticipated.

Now, let's get into the specifics here:

Counsol does not have a clean, modern look like some other EHRs, but the function is the same. For notes, there is one template with mutliple sections. You can choose which sections of the note you want to include or hide, although the note itself is not super customizable (which is a big disappointment for me, personally... you know, since I'm all about making documentation meaningful and personalized!).

The notes provide checkboxes for interventions and the assessment section, as well as free text fields to add other notes, and provides a WHODAS score and diagnosis dropdown list so you can make sure you're staying on track with symptoms. As I've mentioned before, beware relying on the check boxes, which would be very easy to do here and give you almost no info about what actually happened in the session.

Counsol also allows for the option to have separate internal notes (process notes) or specific free text notes that are shared with the client. I really enjoy this feature since it makes collaborative documentation and ongoing communication with my clients really easy. If I mention a resource in session, such as a book or website, I simply include the link or name in the note and they can look it up any time. 

If you don't want to share notes with your clients, this is an optional feature, so don't let that part freak you out.

One big caveat for those of you who tend to be disorganized or fall behind in notes: Counsol does not remind you if a note is not complete. There is no way to tell if a note has been started or finished without actually going in to the client record. So, if you're the type who needs those reminders, you may want to check something else out.

Another option for personalized notes or treatment plans is to add these as a form within the system and write that way, although it's a bit more cumbersome. I do love the form creation within the system so clients can easily sign or complete paperwork ahead of time. And you are also assigned a customer service representative who will help with any set up or questions. No need for emailing a generic info@ email.

ICAN Notes

This may possibly be the most robust EHR available for mental health professionals. It has many cool features that could be conceived as really cool, but possibly overwhelming... depends on your definition of both those words ;)

Within all sections of the EHR there are “shrubs” to prompt you for writing things more easily. These are shortcuts that you can create on your own for phrases or templates you regularly use for assessments, notes, etc. There are also pre-created shrubs if you want to go with what's already there. These seem really useful for prompting counselors on things like what to ask for justification of a specific diagnoses, adding in severity, complexity, writing an MSE, etc.

There are also specific phrases and templates for group and play therapy, which many EHRs overlook. And if you treat substance abuse, there are tons of pre-created phrases and templates related to this, as well. 

There is also a client portal with option to email inside the EHR, show notes to clients, have clients sign paperwork in the system ahead of time, and you can send forms directly from within the system. You can also use a custom form builder and there is the ability for clients to add historical information for assessments prior to coming in.

Yes, this is a robust and potentially overwhelming EHR. However, they do offer unlimited training sessions that are one-on-one, and this is included with pricing. Another feature you won't get from many EHRs. 

Mentegram

Mentegram is a fairly new EHR and is very receptive to customer feedback. I've been impressed by the speed with which they're able to make adjustments to their system and add requested features. This could be a huge benefit to joining in the earlier stages.

This EHR offers the ability to do video sessions within the EHR, which is always a nice feature for clients to have a "one stop shop." There are multiple notes templates (DAP, GIRP, PAIP, SOAP... hm, sound familiar??) as well as a free text note available for anything else you want to write.  

You are able to upload and use any forms, and do scheduling and billing. One really cool and unique feature of Mentegram is the ability to integrate client data from outcome measures or progress based on what clients enter in the client app. Yes, that means you can assign your clients a quick questionnaire to do and the information is uploaded without anyone needing to do anything further!

So, you could assign a client to track their sleep every day or use it to have clients check in about their mood once a week, etc. Other EHRs usually charge extra for anything like this and I really appreciate what Mentegram is doing here. 

PsychScribe

This is an all in one app that you can easily use on your phone or tablet. Yes, this EHR is only offered as an app so it is not currently available on your desktop computer.

PsychScribe has a great layout and simple design, making it easy to follow and use. There are lots of note templates, although none are customizable and there is no option for only a free text note. So, I could see that being needed every once in a while.

If you like a lot of prompts and don't want to think too much about what to include in notes, this might be the EHR for you. The notes can appear a bit long but really would not take long to complete since it is a lot of checkboxes and prompting. It also has specific options for play and sand tray therapy, with the ability to directly upload a picture to the note.

PsychScribe is NOT for you if you bill insurance electronically, unless you want a completely separate system. It is also does not offer the option to charge credit cards, so I recommend using Ivy Pay instead (also an app that's really easy to use).

There is no client portal or ability to upload forms, so you would need to do forms on paper, then take a picture to scan into the client's file on the app and then shred the paper (yes, you can shred paper after you upload it electronically).

Simple Practice

This is a very popular and affordable EHR option that also continues to improve and add features based upon customer feedback. SimplePractice has a beautiful layout that is similar to the clean look of Apple products. It offers a client portal, the ability to upload forms, have clients complete forms ahead of time, online scheduling and messaging, etc.

For notes specifically, you can use their DAP template or create own template. However, you do need to sign up using the mid priced tier if you want the ability to create your own notes template (and you know I always want this ability!). There is also a separate section available for those of you who write process notes, so you can feel they are separated from the main record.

For those of you who need it, SimplePractice does prompt you to write your notes and will keep count of how many notes are pending. However, remember to LOCK your notes after you've completed them. Locking your notes is the same as signing them in the electronic world. Unlocked notes are essentially unsigned notes. 

Most therapists who use SimplePractice love it and recommend it to others. They offer weekly trainings and office hours to ask questions and are very receptive to adding new features that are commonly requested. Plus, they had me speak at their live event last year and then write a guest blog post so I think they're awesome for that ;) 

You can click here to check out my guest blog post on How to Use an EHR Like a Pro.

TheraNest

Very similar to the EHR above, TheraNest offers a simple, clean layout that is easy on the eyes and easy to navigate. There is a client portal, forms uploading, scheduling, and billing. They also offer easy pricing if you want to add other clinicians, charging by number of clients rather than number of clinicians.

Their notes are also simple and allow for customization. They do offer a treatment planner but this wasn't my favorite feature since it seemed overly complicated.  But my personal pet peeve is the whole Goal-Objective-Intervention thing, so that may just be me. FYI- I think you can make goal and objective the same thing, but I'll save that for another treatment planning blog post ;) 

TherapyNotes

Another robust EHR that offers a lot of templates and pre-formatted options is TherapyNotes. One cool features is that notes have the PQRS built in for those who bill Medicare. 

However, you are not able to customize notes or hide features within the pre-created templates and there is a LOT of information in those notes! Some information is required so you have to write something whether you value that field or not. Other sections in the pre-created templates are not required so you could skip them.

However, I never like using this as an option since things get messy when trying to remember what section you completed last time.To avoid this, you are able to rename templates and there are a few different options so you could create your own from a couple of the free text field options. One benefit of using this type of system is learning what you commonly write over and over and then copying and pasting some of those common phrases to save yourself time.

Justin from The Testing Psychologist likes this EHR for easy use with notes for psychological testing. The note adds up time for each test completed, has drop downs for different tests and prompts for other things like to whom the report was released and if feedback was given. Definitely a unique feature and very cool for testing peeps! 

This EHR also pulls in information from the treatment plan and you can use the history feature for previous similar entries to save yourself time typing the same thing over and again (although, beware writing the same notes too often!).

If you do intake assessments in person, this uses a note to complete the intake. The intake note asks for diagnosis justification after assigning the diagnosis. It would be great for people who want reminders in their to do list and reminders for what to write in each section but beware using too many drop downs and losing a more personalized description of what's really going on in your sessions.

Therapy Partner

As far as group practices go, this may be the best option I've seen. Therapy Partner was founded by a therapist with a group practice so a lot of the intuitive and nuanced things about having multiple locations and/or multiple clinicians are integrated with this EHR. For example, you can give permissions to different users so that clinicians can view and document for their own clients, but not see clientele at another location. 

Regarding documentation, Therapy Partner meets my standards for customization! They do have a few standard templates to choose from, with various sections and check boxes for things like interventions. These templates also integrate with the current diagnosis listed for a client (if applicable).

However, if you want to use your own template, you can send them a Word document version of your personalized template and they'll create it in the system for you! I love this service. 

There is no specific or integrated treatment plan within Therapy Partner, but you would easily be able to give them a Treatment Plan template using the above system and then complete that document for your clients as needed. 

They will be releasing a client portal in late fall/early winter 2017. This is probably the biggest feature currently lacking for Therapy Partner but they seem to have a good sense of customer needs so they have been testing this feature with a few current clinicians and it will be releasing soon.

Getting started with Therapy Partner is pretty easy since they offer a free trial. You can also use the promo code "QA Prep" and get two months free, rather than just the typical 30 days to try it out. They also provide extensive help with set up, walking you through things like integrating your merchant account, adding clients and uploading forms. You also have an assigned customer service representative so you have a specific person to call when you have support needs later on.

WeCounsel

WeCounsel is another EHR that offers the ability to do video sessions with clients inside the EHR and gives you that one stop shop for all things client file, billing, online sessions, etc. 

With WeCounsel you can easily add a free text note or use of their many templates. They have a detailed intake template if you prefer to ask questions of clients in person rather than having them do paperwork ahead of time. I also like the ease of adding an addendum to any note- it shows up nicely underneath the note and is super quick for those circumstances when you realize you've locked a note but forgot to add something important.

It is very easy to read through all the notes on a screen by scrolling down so reviewing the file is simple and won't take you a ton of time. WeCounsel does not allow for creating a new template, so you'd have to choose the free text field and add your own template each time for personalized notes. Personally, the pre-created templates have too much info for me, but if you want something really directive, you are able to use them. Again, to each his/her own!

The overall client file interface does not feel very organized and forms are uploaded to show in a long list, which can become confusing if you do scan and upload a lot of forms rather than doing them within the system. 

That's that!

So, what do you think? Do you use one of these EHRs and have additional things you want to share? Don't see your EHR reviewed and want me to reach out to them for a review?  Let us know in the comments below!

Documentation Consultations: Social Media, Insurance and Notes

Welcome to the Documentation Consultation series! 

In this consultation I talk with Julee Cox, a Mental Health Counselor in Florida. We go through some hefty content in this interview and dive in to some of the following topics:

  • How to talk with clients about insurance and confidentiality from the initial phone consult

  • What kind of privacy clients can realistically expect with insurance

  • What to include in your social media policy and why it may be different for everyone

  • Things to look out for when interacting with clients on social media

  • What are "HIPAA notes" and do you need to prepare for them?

  • The most important thing to include in your notes if they may be seen by insurance companies

I hope you enjoyed this interview! If you'd like to sign up for my weekly email tips then you'll also receive copies of the sample notes I referenced, add your info below. 

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Resources we discussed in the video:

You can learn all about creating an initial phone consult script by checking out services from Kelly and Miranda of Zynnyme.com.

You can also click here to check out an excellent book by Casey Truffo, where she also addresses these same issues. 

Tell us what you think about the topics we discussed and feel free to add any follow up questions in the comments below.

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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My 4 Favorite Assessment Questions

Favorite Assessment Questions Therapy

I've mentioned before that clinical assessment is one of my absolute favorite topics, and one of my favorite things about being a therapist. 

I was fortunate that early in my career I was required to complete LOTS of intake assessments and this forced me to become good at two things in particular- time management and asking good questions (not to mention typing and writing quickly, too!). 

So I thought that I'd share with you my favorite assessment questions that I've continued to find useful over time. Many times, asking these questions leads into powerful and detailed conversations about the concerns clients are bringing to therapy

I encourage you to try them out and adjust as much as you like to make them fit with your clientele in each situation.

1) Describe a typical day for you.

I know, I know. The first one isn't even a question! But it's one of the first things I review with clients when they come in and I find it often leads in to getting more details on the way in which their identified problem impacts their every day life. Going through their typical day prompts them to think of things they may not have considered if I simply had them list off general concerns.

By the way, I do actually have them list off general concerns ahead of time in a quick checklist (available in my Paperwork Packet). But this question often leads in to much deeper topics.

Quick Tip: Adjust this for interviewing parents about child clients.

Parents often have difficulty identifying how often behaviors occur in children. It is important to get a detailed picture of this so you can highlight progress along the way, for the sake of both the parent and the child. 

When parents describe problem behaviors, ask how often they occur by going through their day. How often does the behavior occur between waking up and going to school? How often while at school? How often between returning home and having dinner? How often between dinner and going to bed?

This will help you identify times of day that may be more problematic, triggers to behaviors, and also give you a detailed baseline to visit when you want to praise the progress that is being made in counseling.

2) What strategies have you already used to try and solve the problem?

This question is very important to me because it helps us identify what doesn't work, or how to adjust the strategies already used. Most people have already tried solutions on their own or may have reached out to other professionals for help, whether that's another therapist or a religious leader, an acupuncturist, or a psychic.

Dig in to what led them to seeking out those solutions and why they didn't work. Some may have worked up until a certain point or helped with one aspect but could not address the whole problem.

This will often bring up the deeper meaning behind a more superficial problem or identify other areas that impact the problem for which they are coming to therapy. Then you're able to identify how you can best work together, what the focus is, and where is the best place to start.

Lastly, this also a great way to discover your client's resources, network of support, and personal strengths. These are all things you can use within therapy to assist process and progress. 

3) What would you like to get out of counseling? How will you know you are ready to finish?

Somewhat related to #2, I find this question hugely valuable. This is what helps guide me throughout my work with the client because I need to stay on task.

Of course, things may change and new things will come up over time, but knowing the client's goal helps to steer the ship and know whether something should be passed up (perhaps to address later on), addressed head on, and if you may need to take land at one particular problem for an extended period of time.

This is also a way to help clients who are having difficulty transitioning out of therapy. You can point them to their own goals and reasons they would know they are ready to move on. That's why I do document this one specifically, both by asking the client to write this out before seeing me and in my notes for that session in which we discussed it. 

4) Have you ever been arrested?

A little less "touchy-feely" than the above questions, but this question is still one of my absolute favorites that also provides a wealth of information. 

Note that this is different from asking whether or not someone has a criminal record.

This is a really key distinction. The point of asking about arrests is to gather information about potential problem behaviors that may not have resulted in a criminal charge. This also helps to simplify the question because, in my experience, many people do not view misdemeanors or DUI's as a criminal record and will genuinely answer "No." 

This question will be more or less important based on the type of work you do, but it is still an important question to ask every client in every setting. 

Never assume that someone does or does NOT have a criminal record or arrest history based on their presentation! I have had many unassuming people whom I would never predict having a record answer "yes" to this and it has been important for our work together.

For child and adolescent clients, it is important to follow up by asking "Has anyone in the family ever been arrested?" 

Obviously, this can provide information that you would often not receive by simply asking about a criminal record. And, regardless of guilt or charges being made, arrests of loved ones can significantly impact a child's emotions and view of the world. These are important things about which to be aware. 

There are so many things we could potentially review with clients during our intake assessment. 

This is obviously not an exhaustive or required list. But I have found all of these to be very helpful in a variety of work situations, including private practice. Some of them are in my intake assessment that I have clients complete ahead of time, and all of them I definitely review in person. 

What other questions have you found helpful during the assessment phase in private practice, or other settings? Share in the comments below!

Writing a Mental Status Exam

A few months ago I received a question about writing mental status exams (MSE) and realized I've never talked about this! So, here is some direction regarding all things MSE...

What is a Mental Status Exam (MSE)?

A mental status exam is a brief snapshot of a client's presentation. The MSE is meant to assist with diagnosis, capturing and identifying symptoms, but also to create a succinct picture of the presentation at a specific moment in time.

This means that a person's MSE may appear very different at various stages in treatment, and that's perfectly fine. For example, a client experiencing a manic episode will present very differently at the height of the episode than they will during times of mood stability or during a depressive episode. 

I should note that an MSE is always meant to be completed by the clinician who saw the client, and should include a visual assessment (meaning over the phone would not capture many of the applicable sections). 

The MSE is generally more useful for clients with acute, chronic or more severe symptoms. While it can be useful in all circumstances, many sections may not apply to clients with general adjustment or change of life issues. 

When to Use a Mental Status Exam

The most common use for the MSE is during a clinical assessment. The MSE can actually provide a great source of documentation to support diagnoses for clients. If you have difficulty diagnosing or worry about substantiating diagnoses for insurance companies, try using a mental status exam and then make sure DSM diagnostic criteria match up with the identified presentation. 

An MSE is generally completed during the first 1-2 sessions, and then any other time when re-assessing symptoms. 

That might include regular intervals of time, in order to identify progress, or only as needed during the treatment process. It can be helpful to complete one at the end of treatment to highlight any differences in presentation and celebrate growth.

Some clinicians do complete a brief MSE as part of every progress note but I find this unnecessary in most cases. Of course, that is a preference and if using the MSE every time works for you, great! Just remember to include some information about what transpired during the session, as well. 

How to Complete a Mental Status Exam

Like it or not, mental status exams were created to capture dysfunction, not ordinary function. That's why you'll find most of the categories very "clinical" sounding.

For this reason, it is generally acceptable to simply mark "Within Normal Limits" (or "WNL" for short) if there is no impairment found in the identified section. However, this creates that sense of obligation without purpose in documentation that you know I dislike! 

That's why I recommend that if you are using an MSE, then describe each section regardless of the impairment.

And if you don't find this useful, don't do an MSE! Or, perhaps pare down your MSE so that it only includes the sections you find helpful. These don't have to be long descriptions. Remember, the MSE is meant to be a brief assessment, a snapshot. Keep your answers to just one or two sentences, at most. 

Recommended Mental Status Exam Sections

I am listing these alphabetically, in order to keep things simple. However, these are often listed in notes more by level of depth or order of importance. Many sections are often combined so I have either outlined this or included the common names together.

Affect

Different from and similar to mood (below), affect is a bit more descriptive regarding how a client is presenting their mood. For example, affect and mood may both be depressed or sad. The client describes themselves as sad and appears to be so. 

However, affect can also include things like constriction, range of emotion, and appropriate expression of emotion. For example, mood was depressed and affect blunted. In this example, affect is describing the fact that the client exhibited limited emotion, although they may actually be feeling quite depressed. 

Due to the similarities and how these interact, affect and mood are often combined into one section on an MSE "Affect/Mood." I only included them separately here to review the difference between them. 

Appearance

Self-explanatory, this is literally the physical appearance of the client. Note any unusual physical characteristics, grooming and clothing.

Tip: Stay objective here and avoid phrases like "attractive" that can be offensive and subjective depending on the person describing attractiveness. 

Behavior

This is the physical behavior present during your assessment. Here you will note how the client moved and acted physically. This could be something like frequently fidgeting, shaking leg, unable to sit still, or walked very slowly. It may also include things like yelling or crying. 

Concentration

Here you will note any difficulties with concentration, such as difficulty tracking the conversation, frequently getting distracted or going off task.

Insight/Judgement 

A more subjective measure, in this section you will comment on your perception of the client's insight based on the interview. You may note things like how well your client understands the reasons for their behavior or contribution to a problem, whether or not they recognize the severity of a problem, and what is their perception of how to address problems. 

Intelligence/Cognition

Here you can describe the client's abilities based on the information you've gathered so far. In general, this is really meant to capture the more extreme ends of the spectrum, such as significant cognitive deficits or very advanced vocabulary for developmental age. 

Some clinicians will actually test things like working memory briefly during an MSE by doing serials 7's (counting backwards from 100 by 7's), having a client spell "world" backwards. While impairments here may alert you to something, they are certainly not an indicator of actual intelligence.

Memory

You may do a brief test of your client's memory (asking them to remember something at the beginning and then at the end) but then you again have a very low validity picture of memory. It is best to use this section to comment anecdotally on what was noticed during the session. Did your client leave out important details frequently? Have trouble remembering important events or specific periods of time? Also note if they identify any concern about their memory. 

Mood

This one seems obvious and yes, it sort of is. Mood includes common descriptors of how people are feeling and may use traditionally clinical language or more commonly used laymen's terms. These include phrases like depressed, anxious, worried, sad, euphoric, happy, irritable, etc.

Orientation

This is probably the category most commonly used in the medical field and always included in general mental status exams. Orientation refers to how well the client was oriented to person (themselves), place (the setting in which your assessment occurred, as well as their general location), time (date, time of day) and situation (physical and emotional situation). Note that situation is usually but not always included.

This is typically a very brief section, simply noting something like "Client was oriented x4" or "Client was oriented to person but not time, situation or place."

Perceptual Disturbance

This section has some crossover with thought process and content but could be used to highlight things like hallucinations, if that is a common symptom you see. If so, identify the type of hallucination (e.g. auditory, visual, etc.) and any relevant info.

Speech

Another self-explanatory category, here you will consider anything related to speech quality. This includes things like speech impediments, rate of speech, volume, etc. 

Strengths

This category is not always included in common MSE templates, but I always work from a strengths-based and client-focused perspective, so I'm including it here. You can identify strengths you noticed during your meeting with the client, and also ask the client (or parent/guardian) to identify strengths.

Suicidality/Homicidality

Here you will acknowledge your assessment of these areas and specifically note whether or not the client denied these, has a plan, has ideation only, etc. 

Even if your client was noted to be suicidal with a plan, don't feel the need to include extra information here. That will all be in your progress note where you describe your assessment in more detail, along with the identified plan. 

Thought Content

This section captures what was the main content your client presented during your session, as well as any noteworthy content items that came up. This may include delusions and hallucinations, if you prefer not to have a separate category for these symptoms. 

Regardless of things like delusions, this is also the area to include things the client focused on as important. That may be feelings of guilt, preoccupation with a particular topic (video games, sex, a specific person, etc.), irrational worries or even phrases that were repeated throughout. 

Thought Process

While content focuses on what was discussed/presented, process focuses on how the client presented that information. This includes things like ability to think abstractly, connections made as explanation for behaviors or mood, associations and ability to stay on track, flight of ideas, or magical thinking. 

Yes, there may be some crossover here with things like concentration and insight/judgement but this section really pulls those pieces together to describe how the client views the world and themselves.

Create Your Own Mental Status Exam

If you're in private practice then you have the flexibility to use which sections you like, complete an MSE whenever you feel it is relevant, or even avoid it altogether

I recommend you look through the sections and then identify anything you think would be helpful to document during intake assessments, then anything that may be helpful to track over time at various intervals, and anything you'd like to capture at the end of treatment for a more objective view of progress. 

You may find certain sections more or less relevant for different clients, and that's okay. Think about your current clients. If a section applies to at least half of them, then it will likely prove useful to you. If not, then scratch it and just add that in when it's needed.

You can also create an "Other" category for random things that come up but don't fit anywhere else. Simply use that as your catch all and then take note if you find yourself including the same thing over multiple clients. Then maybe it should become it's own category.

You have the power here to make the mental status exam whatever you'd like it to be for your practice. So make it meaningful to you and helpful to your clients. Otherwise, there's no point!

Let us know in the comments below... do you use a mental status exam in your practice?

What tips have you found to make it meaningful and easy to complete? 

Writing Your Client's Journey: Interview with Jo Muirhead

While blog posts are helpful, sometimes you just want to hear what someone else is doing and model things after them! That's what I'm doing with the regular "Writing Your Client's Journey" series and to kick things off I interviewed a very successful group practice owner in Australia, Jo Muirhead

Jo shares some excellent tips on things like streamlining, creating systems and encouraging your motivation to get paperwork done.

You'll notice some sound distortion in just a few spots but it's very brief and there's a ton of great tips so stick with it! And if you've only got a few minutes to check things out, scroll down further for the interview highlights.

My favorite quote from this interview is early on when Jo says about paperwork and systems, "If you can't learn to love it, you've got to respect it because hating it helps nobody."

In the beginning of her practice, she tried to customize her systems and forms to meet each individual client's need but then found out that wasn't working as her practice grew. So, Jo started to create systems for getting all the mundane but necessary stuff DONE.

Creating a system for yourself makes things more simple and easy. Without these in place, you can easily be distracted from the work you really want to do- your clinical work with clients. 

Prepare for growth by having directions for things written down for anyone who may need it later on (e.g. an assistant or a new clinician). This can save you hours of time... Jo and her team set up one system that turned end of month financials from a 10 day task into a two day task!

Specifically, some tips that Jo shared during the interview are: 

  • Set up a checklist for each task

  • Create a centralized place and system for all tasks

  • Teach a child or a partner (or team up with another clinician) how to implement each task to identify holes in the system

  • Schedule everything (especially notes and accounting)

  • Use LastPass to manage all your passwords for every site that requires a password

Important things to focus on streamlining: Intake and discharge

Important things to keep up with regularly: Notes and bookkeeping

Jo also had a great tip for those times when you become overwhelmed by a task. Ask yourself, "What could I have done to make this easy on myself?" Then focus on changing that one habit to improve things in the long-term.

And the big payoff from putting in all this work? Once you have a clear idea of how long it takes you to complete a task, you can decide if it will be worth delegating and, if so, you know what to expect from that person!

Feel free to share in the comments below. What have you found helpful for simplifying paperwork and other administrative tasks? 

Want to learn more about Jo and the coaching services she provides for others? Click here to learn more!

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!

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

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

Paper Records

Pros:

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

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

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

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

Cons: 

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

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

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

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

The In Between

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

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

Electronic Records

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

Pros:

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

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

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

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

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

Cons:

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

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

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

Some Cons to All Methods

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

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

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

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

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

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

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

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

Do a review of your client's file.

Before you stop reading, let me explain!

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

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

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

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

1. Go back to the very beginning.

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

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

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

2. Evaluate your treatment plan.

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

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

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

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

3. Review your notes from day one.

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

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

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

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

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

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

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

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

When Outcomes Don't Matter

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

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

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

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

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

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

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

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

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

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

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

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

What's going on?

Was this result a surprise or expected?

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

If this was a surprise, how come?

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

How do we feel about this?

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

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

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

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

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

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

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

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

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

Casey Truffo and being the CEO of your private practice

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

Kelly Higdon and integrating coaching into your practice

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

Keri Nola and using your intuition in your private practice

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

Jo Muirhead and creating a successful money mindset

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

Camille McDaniel and adding clinicians to your practice

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

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

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

Roy Huggins and using technology to serve your clients

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

Melvin Varghese and starting a podcast 

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

Ernesto Segismundo and using video to promote your practice

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

Kat Love and creating a beautiful website

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

Clay Cockrell and providing counseling online

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

Barbara Griswold and responding to insurance inquiries

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

Samara Stone and building a practice based on insurance

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

Nicol Stolar-Peterson and creating a court policy

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

Agnes Wainman and identifying your ideal client

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

Allison Puryear and networking your way to success

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

Stephanie Adams and creating systems that sustain your practice

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

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

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

How to Personalize Your Intake Assessment Form

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

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

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

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

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

Client Contact Information

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

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

About You

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

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

Family History

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

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

Employment/Education History

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

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

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

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

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

Medical History

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

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

Mental Health Treatment History

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

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

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

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

Substance Use History

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

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

Other

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

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

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

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

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

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