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!

10 Tips for Documenting in Crisis

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

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

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

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

If you're providing services in your office:

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

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

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

Writing Less is Writing More: Reducing the length of your notes

Regarding length of notes, I typically hear two things... either "You'd probably wince if you saw how little I write" or "I feel like I write too much."

One thing I recommend for both issues is to use a regular notes template and pair that with the note writing prompts available in my free Private Practice Paperwork Crash Course. But for those who write too much, even that won't necessarily solve the problem.

This is something I've had to work on myself, since I tend to be wordy. I've also had a lot of experience with more unstable clients who required a little more documentation than the "average" therapy session. Side note: when dealing with crisis, make sure to clearly spell out your actions and the rationale for those actions. Include a follow-up plan and then document the actual follow-up. 

This made shortening my notes a little more difficult but as I've worked it through it, I figure I'll help you do the same! Let's take a simple notes template, like DAP (Data, Assessment, Plan), and look at how we could pare down a long note...

Here is a note for our hypothetical client, Maya. We'll look at each section separately to see what things we can take out.

First, let's check out the Data section:

Long Version: Client arrived five minutes late to session. She looked really stressed and was in her workout clothes. I offered her water and had her sit down. Reminded her of the mindfulness exercises we reviewed last week and asked how she did with practicing them over the last week. She talked about difficulty concentrating and about how her son kept interrupting her so he could get help with homework. She asked her mother to help him but she was busy as well. Client spent much of the session making excuses for why she probably won’t be able to implement the exercises at home. She then started talking about wanting to go on a “girls’ retreat” for the weekend with some friends and how it’s the only thing that helps her feel better these days. She was reluctant to leave the session at the end and said, “This is so helpful. Thank you for being here for me. I don’t know what I’d do without this.” Then left immediately.

You may notice a LOT of extraneous information. There are also lots of details that aren't necessary. This is just a matter of sticking to the most important facts and taking out our really specific language. Here is how we can make this note a bit better (and shorter):

Short Version: Client arrived late and appeared flustered. Reported feeling stressed and having difficulty implementing mindfulness based exercises previously reviewed in sessions. I assisted her in practicing the techniques and problem-solving ways to implement at home.

See? The details about difficulty making a decision on whether or not to attend a girls' retreat and exactly how she attempted the mindfulness exercises are irrelevant. We still get a good sense of how she is progressing and what happened during the session without having a total play-by-play.

Now, let's look at the Assessment section:

Long Version: The client seems resistant to implementing practices discussed in session and continues to be stuck in a recurring cycle of promoting her anxiety. She appears to prefer excuses to trying to work on her goals. She continues to use her son as an excuse so she does not have to focus on her own needs or working through her own issues with guilt and anxiety. However, also presents as somewhat codependent, declaring how helpful therapy is even though she doesn’t follow through.

Okay, for this section we have some quality concerns... namely, the very subjective language. How do you think Maya would feel if she read that? Probably not great. I'm not saying our goal with notes is to appease our clients, but we should be respectful and as objective as possible, even during a more interpretive section like the Assessment. 

So how could we word this differently and also make this shorter? Let's see:

Short Version: Client is having difficulty managing her needs with family demands. Remains committed to therapy.

Did that just blow your mind right now? It's so short! But really, considering this session, there's not much more we need. We already discussed her difficulty implementing techniques in the Data section and there's no need to harp on that point. 

Instead, we focus on what all the stuff in the Data section means as far as what we really need to be working on. We also kept things very objective while adding something positive about her treatment thus far. 

Okay, now let's look at the final section, the Plan:

Long Version: Client will try using meditation and journaling again over the next week. She will update me on her progress with mother and son. We’ll meet again on 06/02/16.

This section is pretty easy to keep short, regardless, so I didn't make as much of a change here. But I did take out the extraneous information and simplify things... 

Short Version: Client will practice exercises reviewed in session. Next session is 06/02/16.

And there you have it... a great, simple note! I want to summarize a few pointers based on the differences between these long and short versions:

  • Remove extraneous information that's irrelevant to treatment or progress.
  • Remove the “gory” details and use more general language.
  • Keep the general focus of the session as the focus of the note (without letting other things distract you!).
  • Leave out subjective language and consider how your client would feel reading the note
  • Leave in client quotes if they're relevant. They often say more than any interpretation you could create.

If you liked this breakdown of how to simplify your notes, you may also want to check out my upcoming trainings and my paperwork packet. I not only offer forms (which includes four different note templates) but also spell out directions for how to implement them. 

I love doing this stuff and if it helps you, everybody wins!

What were your takeaways from this post? Any ways you can improve your notes? Write a comment below and let us know!

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

How to Personalize Your Intake Assessment Form

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

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

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

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

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

Client Contact Information

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

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

About You

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

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

Family History

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

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

Employment/Education History

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

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

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

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

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

Medical History

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

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

Mental Health Treatment History

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

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

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

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

Substance Use History

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

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

Other

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

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

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

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

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

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

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

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

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

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

That's why I'm here ;)

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

Narrative

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

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

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

Structured

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

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

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

Diagnosis based

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

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

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

Client-centered

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

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

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

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

Simplifying Your Informed Consent

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

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

Make it a conversation

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

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

Give examples and explanations

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

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

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

Use layering

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

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

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

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

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

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

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

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

What is a Notice of Privacy Practices?

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

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

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

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

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

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

How to Supervise Clinical Documentation

Although some counselors may feel “okay” about their own documentation, few know how to teach this skills to supervisees. And if you struggled with documentation or feel less confident then this becomes even more of an issue.

In this post I’m laying it all out for you… how to train supervisees, how to correct work when needed and how to integrate this teaching into your supervision so it doesn’t take away from the clinical conversations you need to have. So check out the steps below and see if any (or all!) seem like good things to try out with your supervisees.

Reviewing paperwork

1. Read through the notes as a story, not one by one.

The tendency when reviewing notes is to read them week by week for each client. However, when you read only one session note you miss out on the whole clinical picture. Was there something important that was never followed up on? Does the treatment seem to be following a good flow? Have there been any patterns that emerge over time?

2. Check to see if the reason for treatment is clear.

Can you tell, just from reading the assessment and intake notes, why this client is here for treatment? Are you able to identify a clinical need or goals from the client? These should all be evident in the paperwork but should also match your supervisee’s description when you discuss the case.

3. Make notes about what questions come up as you read.

It’s very easy to get caught up in reading a file and forget key points along the way. Use a simple sheet of paper to jot down comments and notes to yourself. Don’t forget to highlight things that are well-written so you can also give positive feedback!

Training on paperwork

1. Write notes together.

One easy way to train is to simply write the notes in your supervision meeting while talking with the supervisee about the session. This allows you to teach them how to summarize and highlight what are the important points while leaving out “fluff” or extraneous details. Another method to this is to watch a sample therapy session together and write notes on the session individually, then share how your notes are similar or different and see what you each focus on. I’ve experienced great success using this strategy with even seasoned clinicians. If you have a group practice or supervise more than one person, this is a great group technique!

2. Talk about treatment planning and how that looks in real life.

Don’t neglect treatment planning with your supervisees. What I find when I talk with therapists about their treatment plans more often is that they tend to adjust them more often. And that’s okay! Check in to see where treatment is going and if things need to shift. That may mean the treatment needs to shift a little to better meet the client’s needs or it may mean the treatment plan needs to be adjusted.

3. Review one file each meeting.

This will insure the notes are getting done, which is a big piece about documentation! It’s very easy for counselors to fall behind in notes but if you’re regularly reviewing at least one file you’re more likely to see a completed file or to at least catch a problem early. This will also create a habit of reviewing files for both of you.

4. Create an action plan for catching up on notes. Keep them accountable to it.

This is HUGE! As soon as even 1-2 notes are missing, make a plan to catch up and check in. As the supervisor, I do believe it’s your job to follow up and make sure this doesn’t become a bigger problem. Be supportive but also create a firm deadline and provide the needed time to meet that deadline.

5. Have your supervisees attend a training. Even better, attend together!

Shameless plug here, I’ve got a couple trainings on this topic, at different levels of intensity. Check out the Meaningful Documentation Academy to see if investing in even just a 45 minute training may help your team. Part of the reason I do what I do is that not many others are doing it so I don’t have a ton of other resources to give in this area, but seek out your local professional association to see if they’d be willing to sponsor a training on clinical documentation. When these do occur, they’re typically very highly attended.

And if you're reading this is a supervisee, suggest some of these with your supervisor! Many supervisors are nervous about documentation as well but if you start the conversation, they are likely to help you out.

Now tell us… what strategies did your supervisor use that helped you with documentation? Any lessons learned that you can share? I’d love to hear in the comments below!

Therapists Need to Forgive Themselves

In my work with therapists there is one overarching theme I see that has a detrimental impact on their documentation, but also their well-being. And that theme is feeling shame.

Shame about getting behind in writing notes. Shame about not knowing what a treatment plan is supposed to include. Shame about not knowing whether or not they're putting the right amount of information in their notes.

Brene Brown writes that "Shame creates feelings of fear, blame and disconnection." That's exactly what I see. Therapists who feel this shame are often fearful of others (especially other professionals) seeing their documentation. The thought of a subpoena or records request is terrifying.

Many counselors will beat themselves up for not knowing all these principles, regardless of the fact that they were never given adequate education/training on the subject. And that leads to a vicious cycle where counselors who feel inadequate then avoid training new therapists about documentation and so on.

That leads us to the disconnection piece. We're all in these offices, isolated and fearful. The last thing most therapists want to do is broadcast that they have no clue what they're doing when it comes to paperwork. So they search the internet for answers or avoid it all completely, never doing the most important step in this situation which is to seek out consultation and training. 

But I understand the step of reaching out may be very difficult when caught in the middle of that shame sh*t storm! So I've got some steps for initiating a practice of forgiveness and acceptance first. If you can do this on your own then it may be easier to reach out to a colleague for support.

Forgive yourself for messing up

Yup, we all mess up. Thankfully, we're not surgeons and our mistakes aren't likely to kill anyone but they can sure feel awful just the same. But would you talk to a first year graduate student and tell them you never expect them to mess up after graduation? Of course not! That's ridiculous.

So own your mistakes. They often provide invaluable lessons that you'll carry with you for years to come. I'll be the first to admit I hate making mistakes but they still happen. And while I may have a little freak out moment initially, they've always provided me with great information on how I can improve something.

You know what else? Mistakes usually help me create more community. When I reach out to colleagues for support the response is overwhelming and I end up feeling much more connected than I had before. 

Forgive yourself for feeling like you don't know what you're doing

Even after you've been licensed for years there is waaaaaaay too much information out there to know it all. And if there's a topic about which you never received specific training (ahem, documentation!) then of course you'll feel like you don't know what you're doing!

So let's just get fight that point right now with some truth: If you don't know, that's okay. This is an opportunity to learn. In our mental health field things are constantly changing and improving. In order to stay up on things we must continue to learn. 

If no one ever told you how to write notes or what to include in a treatment plan, sign up for my free Private Practice Paperwork Crash Course. It's meant to give you an overview of all aspects of documentation so you can have a better foundation. 

Forgive yourself for getting behind in notes

This is the most common experience of shame that therapists talk about with me. Whether it's two weeks, two months or a year of notes, getting behind is extremely stressful. What increases the stress is the feeling of not knowing how to catch up and feeling embarrassed to reach out for help. 

It's like you're drowning, you know you're drowning, and there are people nearby who can help. But you're scared to yell out to those people because you're not sure if they'll give you a hand or react in disgust and push you down further. 

This speaks to a few things. First, the importance of having trusted colleagues in your corner so you can reach out for help with confidence. Second, the importance of identifying the problem early so you can address it before things get too out of hand. 

But the piece of this metaphor that's missing is the shared experience. Because there are typically many other therapists drowning with you, but you think they are easily treading water. The shame of drowning in paperwork keeps us from sharing this information. 

I'm here to tell you that it's rare to speak with a counselor who hasn't fallen behind in notes at least once or twice. And it's actually pretty common for therapists to get stuck in a cycle of getting behind in notes by a couple weeks, catching up, falling behind again, etc.

Let me say that again, it's common for therapists to fall behind in their documentation. 

While this obviously isn't the ideal, I think it really helps to know that you're not alone. If you're brave enough to reach out for help you'll likely find someone else who shares your experience. So I would really encourage you to reach out if this is a struggle for you. 

You can also check out this blog post on How to Catch Up on Paperwork if you need some practical tips for getting started. 

Let me know in the comments... are any of these areas in your life you need to forgive? Have you had an experience of overcoming shame around documentation? I encourage you to be brave and fight fear with action! We're all here to support you. 

 

How to Organize a Client File

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Therapy Notes: A Self-Quiz for Counselors

You’ve maybe heard me talk (or really, write) about feelings and documentation before… I like to normalize a lot of what I hear from therapists. Because I hear it ALL THE TIME.

"I don’t know if I’m writing notes the “right” way."

"I hate writing notes and avoid it but then I get backed up."

Well, in this post I’ve got a tool for you to dig a little deeper and see what it is that’s really causing problems with your notes… and what it is you’re doing well already.

Check out the questions below. They’re all really simple yes/no questions related to how you write notes. No one else is watching so be honest with yourself! And if you want a pretty version to download, click here.

The Self-Quiz

  1. When I sit down to write notes I know exactly what to say.

  2. I know how to calm my mind when my thoughts are racing.

  3. When I think about writing notes I feel calm and confident.

  4. I can easily put into words what “progress” looks like for my clients.

  5. If a client asked to see their records, I would feel comfortable letting them read my notes.

  6. I know how long it takes me to write a case note.

  7. I know what time of day is best for me to reflect and be quiet.

First, let’s analyze what it was like completing the quiz…

What triggered you emotionally? Was there a question that elicited fear, guilt, resentment, anxiety? Take a moment to write down what those feelings are and why.

Acknowledge any prior negative experiences with documentation. Lots of therapists tell me they’ve had a bad experience with a prior supervisor or with having records examined by insurance or requested from a client. That’s okay and it doesn’t have to dictate how you feel about writing notes from now on.

Now let’s check out your answers. Obviously, we’re looking for “yes” answers to all (or at least most) of the above questions.

Was there an area in which you felt confident? What questions were a clear yes? Those are your strengths related to documentation.

And the no’s… are they mostly emotional or logistical? Some people feel okay about their documentation but they need to get the logistics of creating time for writing notes improved. They know what they’re doing for the most part but tend to fall behind easily and then get overwhelmed by the sheer volume.

Others may have a clear idea of the general time it takes and be diligent about writing notes regularly but notes still produce a feeling of anxiety or resentment. You may not feel confident that the content is “up to par” or feel unclear about what should and shouldn’t be included.

Once you have a clearer idea of where to focus your energy (and what to keep doing well) you can take steps to improve it.

Want someone to help you write some notes and actually review them? Schedule a time with a colleague or check out my individual consultation services.

Looking for examples of different types of notes to write? Sign up for my (free) Private Practice Paperwork Crash Course to learn about four different templates to use for notes and see some examples.

Go through your “no” answers and choose just one to work on. See what resources are best suited for that and then take action! There’s no better time to improve your notes than now!!

What’s your next step? Leave a comment below so we can follow up :)

Mental Health Paperwork: Get Organized and Save Time

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

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

Administrative Paperwork

1. Have clients complete paperwork ahead of time.

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

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

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

2. Review forms with your clients in person.

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

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

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

3. Do your assessment form via conversation.

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

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

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

Organization

1. Use an electronic health record (EHR)

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

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

2. Use a billing expert.

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

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

3. Integrate your calendars.

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

4. Alphabetize everything.

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

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

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

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

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

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

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

Why Insurance Billing is Like a Wedding: For every therapist who provides a super bill

Do you provide a super bill to your clients so they can be reimbursed by their insurance company after they pay you? 

You may think because you choose not to contract with insurance yourself that your client's records are protected. Well, that's only partly true. 

You see, when clients choose to allow their insurance company to pay for their counseling they are entering into a "deal" with the insurance company. They're essentially letting the insurance company call some of the shots related to their treatment. 

What does this look like? Well, that depends on lots of things but mainly on the insurance company and your client's plan. 

To give you a real world picture of how this plays out, let's look at this common wedding scenario:

Your parents offer to pay for the reception at your wedding. This is quite a large expense and you're very appreciative. In fact, you may not even have a reception if they weren't willing to pay. You graciously accept their offer and begin planning.

Things are going well. Your mother helped you choose the food and it's going to be delicious. You sit down with her one weekend to plan out the seating arrangements... and things take a turn. She has a different idea about the priorities and order of seating.

You may argue for a bit but in the back of your mind you know: she paid for this. Can you really just tell her no? How much say does she get? 

And think of the mother's argument for a minute... she has invested all of this money, very willingly. But she wants to make sure this expensive event will be "all that it could be." She may understand some dynamics the bride is unaware of or may have thought differently about her level of input from the very beginning. 

Insurance companies are similar in that they have a vested interest in your client's therapy. To put it frankly, they are "footing the bill" and they want to make sure they are getting their money's worth

Keep in mind this isn't necessarily a negative thing. If your client understands this process, is fine with it, and using insurance makes therapy more easily accessible to them, GREAT! 

But if your client doesn't understand that there are certain rules to follow and no guarantees about ongoing payment, this can be quite a shock. And it's my belief that it is your job to tell the client about this scenario.

You may be thinking, "but that's exactly why I choose to do the super bill thing rather than have a contract with insurance companies, so I don't have to think about this stuff!" Totally understood, and you're right. It's not your job to think about all the insurance requirements when you don't even have an insurance contract.

But it is your job to explain the limits of confidentiality. And as soon as you choose to provide that super bill, I believe it's your ethical duty to explain to your clients the realistic expectations to have with insurance, reimbursement and confidentiality. 

It doesn't have to be a long conversation! And you can phrase it many different ways... but yes, I do have some tips for what you can say... or you can just steal my wedding scenario.

  • Explain that insurance may limit things such as how much they're willing to pay per session or how many sessions for which they'll approve payment. Discuss what this means for the client as far as out of pocket expenses and expectations. 
  • Explain that once insurance is paying for something they have the right to follow up and see how things are going. This is typically either via phone or records request. 
  • Make sure clients understand if they choose not to allow records to be released when requested, insurance may choose not to pay for those services.
  • Inform your clients that any super bill or anything submitted to insurance related to payment will require a diagnosis. Discuss with them possible ramifications of this (like implications for life insurance coverage). Also let them know what their diagnosis will be, why and insure they understand that piece. Note: It is considered insurance fraud to inaccurately diagnose a client in order for them to obtain coverage. 
  • Stay focused on the part you know. Don't try to guess what the insurance company will or won't cover. Refer the client back to their carrier for questions related to coverage.

For many clients there are very few issues and things run smoothly, requiring little work on your end. But in those circumstances when requests for records or denials of payment come up, it's best to be prepared.

Let us know in the comments below if you have any further tips for explaining to clients the relationship between therapy and insurance. And feel free to share any resources as well. 

I have some on the QA Prep Resources page and you're welcome to ask questions below.

Taxes and Your Counseling Practice: Q&A with Jennifer Bierds, CPA

This blog is a little different but suuuuuuuper important for therapists in private practice to consider... Jennifer Bierds, CPA is answering your tax questions! 

I surveyed a group of therapists to see what were the most common or applicable questions, then I shot them over to Jennifer. She's got some great insights for you so check it out...

1. Can I use the time I give free sessions (pro bono sessions) as a deduction of some kind?

Generally speaking, the lost income from providing free sessions to regular clients would not be deductible.  I’ve had the same question regarding “no shows”.  Basically, you can only have deductions if you have corresponding income to deduct them from.  Therefore, if there was no income received, no deduction is allowed.

However, if you are donating your time to a charitable organization, the value of your time could be considered a charitable contribution.  The deductibility would be determined based on the circumstances, as would the value.  I would recommend consulting with an accountant to help you sort out the specifics.

2. How can I get more write offs? How close can I get to the “edge?”

Document every single expense and keep receipts!  The IRS says any expense deemed both “ordinary and necessary” to conduct your business is deductible.  So if you can justify it, count it as a business expense, no matter the amount.  Those receipts add up over the course of a year, and when you’re self-employed, every little bit helps!

Aside from business-related purchases, there are numerous other ways to reduce your tax liability.  Keep track of your miles driven for business purposes, contribute to a retirement fund, donate to a local charity, the list goes on and on.   Working with someone who specializes in tax planning is the best way to minimize your taxes, and you’ll most likely save more than you would spend for the service.

3. Should I be an LLC, INC, S Corp or SP and why? What is the difference?

Note: This may be state specific!

I’m going to assume that you are a single practitioner working in private practice on a contract basis, which is the most common scenario (there are several factors to consider when deciding on a business structure, so this is not going to be all-encompassing). Most people in this situation would either opt to be an LLC or an S Corp.  Technically, you could be an LLC and elect to be taxed as an S Corp (as is the case in Texas).  

The main benefit to either, as opposed to working with a DBA or Assumed Name, is that you have limited liability, meaning your personal assets are protected in the event you are faced with a lawsuit - thus, the “limited liability”.  Many people start out as working under as a single-member LLC.  Essentially, all of your business income is reported on your 1040 Schedule C, and flows right through on your personal return.  

At a certain income threshold ($100,000 is the generally accepted number), it becomes more beneficial to elect to be taxed as an S Corp.  Doing so reduces you self-employment tax liability because you are now paying yourself a salary.  With this salary also comes the requirement to pay payroll taxes, and filing quarterly and annual payroll tax returns, however.  You would also be required to submit an 1120S in addition to your 1040 at tax time.  

4. How do I know when (or if) I'm supposed to file quarterly taxes?

Anyone who expects to owe at least $1,000 in annual taxes is required to make quarterly estimated payments.  The payments are due around mid-month in the month following the end of the quarter, depending on the way the days fall during the year.  Usually, when your tax return is prepared, you will receive vouchers to make estimated payments for the coming year.  When in doubt, consult your tax advisor, or do a little research on IRS.gov, which is actually very helpful.

5. What do I need to do to remain compliant? And who can actually do this for me?

Depending on your business structure (LLC, DBA, S Corp, etc), you can be expected to submit any number of tax returns or informational forms throughout the year.  These will also vary according to your state’s requirements.  Most CPAs can help you get through the year without default.  

6. How do I find the right tax person for me?

Do your research - ask your friends and family for referrals, look around online, then contact a few candidates.  Especially since you are self-employed, you need to have the guidance of someone you can trust and feel comfortable with to help you navigate all of the regulations and requirements that come along with running your own business.  

Find someone who will take the time to listen and answer all of your questions.  If they don’t return your phone call or e-mail within 24 hours, move on.  Some accountants forget that we are in the business of working with people, not just their money, and let customer service fall to the wayside.  

So there you have it! Tax season is stressful enough and having some answers to basic questions or direction on where to go for more help is priceless. If you have more questions, feel free to post in the comments below and we'll make sure you get some answers. 

About Jennifer: 

After spending 10 years in the banking industry and having a baby, I felt it was time for a career change.  I’ve been doing my counselor husband’s tax returns since we started dating 11 years ago, so accounting seemed to be the natural choice for the next step for me.  So, with a growing boy at home with a very supportive husband, I spent many late nights in class and studying.  I’m now a fully licensed Texas CPA, working on taxes and bookkeeping for a wide range of clients, from individuals to small corporations.  My specialty is working with professional service-based businesses to keep their "back office" running smoothly and optimize their financial potential.  My practice has fully virtual capabilities, so I can help anyone, anywhere, through secure online interactions within my website, www.BierdsCPA.com.  

And for the record, our son says he’s going to be an accountant when he grows up :)

Writing Therapy Notes: The Advice I Give Every Counselor

Do you ever find yourself saying the same thing over and over again? I talk with hundreds of therapists and I certainly find myself sharing the same pieces of advice each month. 

So what better use of a blog than to write down those most commonly given tips on writing notes?! Below are my most common answers when presented with various problems or questions related to notes... 

Choose a theme for the session

Take a moment to think about the main topic you and your client (or clients) reviewed in the session. You may have jumped around to a few different things but don't focus on the minor details. Stick with the general theme and leave the rest out!

Note: Of course, any time there are safety concerns, this rule goes out the window and you want to carefully document your actions. 

Create a regular schedule

Many therapists think they'll squeeze in a few notes between sessions or randomly complete them throughout the week. Ever hear that saying "Fail to plan and plan to fail"... yeah, that totally applies here. Make sure you have time to do your notes that is separate from time you plan to spend on other administrative tasks (like answering emails and phone calls). 

And make your schedule realistic. Do the math to see how much time you'll need. For example, if you see 15 clients per week and spend about 10 minutes per note that is 2.5 hours you should plan to spend each week on notes. 

That's pretty reasonable for most people... but if the thought of spending two and a half hours (or more) on notes each week for the rest of your career makes you want to throw up, consider checking out collaborative documentation for at least some of your clients. You have options, but make sure you figure out what works best for you so you can be successful. 

Simplify your template

Many therapists start out in private practice using all the documentation techniques their previous supervisor used. But (a lot of the time) that doesn't work out so well. I'm assuming you started a private practice to have some freedom in the way you do therapy and guess what, that applies to your notes, too!

Choose a simple template you can use with all your clients and stick to it. If you want to try out a few different ones, I recommend staying consistent for at least 1-2 weeks to see if you like it. Once you get the hang of writing the same way consistently, you'll have to think about your notes less. They'll start to flow. 

If you want some tutoring on various templates and how to use them, check out my free Private Practice Paperwork Crash Course. I go through four different templates- DAP, GIRP, PAIP and SOAP. 

Wait on using check boxes

This is a biggie. Lots of counselors ask me for check boxes, how to create notes with check boxes, lists of interventions, etc. The thing is, I could give you a list with hundreds of options but that would just be overwhelming. And there's no way I can personalize something like that for you without first evaluating quite a few of your notes, your therapy style and getting a sense of your typical client.

So my recommendation is to create the easy template with check boxes later. First, write your notes using a sentence structure and one of the templates described earlier. Then, after you've been in practice for 6-12 months, evaluate all your notes and pick out the common interventions you provide. You can do this exercise in about an hour. 

Do that and you'll have a very personalized list that will truly save you time, rather than searching through some pre-made template where half the options don't apply to you. You can click here to watch my interview with Rajani Levis, a therapist in San Francisco who used this method to create her own notes template. 

Be wary of taking "quick notes"

Many therapists fall into the trap of jotting down a few quick notes to themselves at the end of a session, with the intention to write the full note later, tomorrow, etc. It seems like a good idea initially because you're making sure you don't forget something, knowing you don't have time to write the note at this moment... but this actually creates a false sense of security.

What commonly happens is the therapist holds off on writing notes, thinking they've got everything covered. Then the pile snowballs and five months later they have hundreds of notes to write (yes, literally... this happens a A LOT). 

Obviously, no one wants to end up in the same situation without the quickie notes to remind them of what actually happened three months ago in that one session with so and so. But I have a theory that most therapists who get behind never would have let themselves get to that point if they didn't have those notes as a "safety net." 

Seriously, if you follow these five tips you will find yourself avoiding many of the problems counselors commonly run into. 

"Did she just say commonly run into?" Yup, I did! Because most therapists do fall behind on their notes at some point. And most therapists feel insecure about their note writing skills.

My personal mission is to change all that, for good! I want to make sure we all have the support we need to succeed.

That's why I created the free Private Practice Paperwork Crash Course, write weekly blogs, do monthly webinars (found in the Meaningful Documentation Academy) and all kinds of other things... to eventually replace this fear of documentation with confidence and, dare I say... excitement!

You can also learn more about writing notes (and get 2 NBCC approved CE credits) through my workshop The Counselor's Guide to Writing Notes** or learn some great tips from my ebook Workflow Therapy: Time Management and Simple Systems for Counselor's.

It's a journey, a process, and I'm here with you for the long haul. So make sure you share these resources and let's keep encouraging one another whenever we can. 

Until next time, happy writing!

**The Counselor's Guide to Writing Notes is now exclusively available through the Meaningful Documentation Academy.

Insurance Documentation Made Easy (for Therapists)

Have you ever tried to research the answer to a question about insurance billing or documentation? You'll wind up with all kinds of resources that are often overwhelming.

Worse yet, ever post an insurance documentation question in a Facebook group? You're bound to get five different answers to the same question! 

Why does this happen? How come the answer isn't easily accessible?

Because each therapist provider has a different contract, with different stipulations. That means you and your therapist friend may each have a contract with Magellan but actually have different requirements for billing.

What's the takeaway then? Don't blindly follow someone's advice about your contract with the insurance company! Instead, I recommend you always contact the company directly to get the answer to your question (or read through your contract). 

Don't feel disheartened, though. There are a few things that are pretty universal in the insurance world. Those things are billing codes and the concept of medical necessity

And because I like to make things nice and easy for you, I have a nice little cheat sheet with common billing codes (CPT Codes) that counselors use. Click here to download the cheat sheet.

This cheat sheet is part of the insurance lesson in my online program, Meaningful Documentation. There are plenty of other cheat sheets you can find if you do a Google search but this one is very specific to the common codes therapists in private practice use. Plus, I give you a little description of when each code is used. 

Remember that whether or not you're actually allowed to use each code is dependent on your individual contract but this should help you determine what is needed and when.

I also recommend you hop on over to one of my previous blogs, Top 5 Things to Know About Insurance Billing, if you're new the insurance world or simply searching around for answers. This topic can become overwhelming very easily but that's not necessary!

Make sure you know your contract and understand medical necessity first and foremost. Then make sure you're using the correct documents (like a Notice of Privacy Practices) and sharing with your clients the limits to their confidentiality. 

Then keep doing the awesome work you do! And make sure you're on my email list so you get notices about other cool blog posts like this one ;)

Hope you find the cheat sheet useful and let me know how it goes! And happy writing.

A Counselor's Story of Falling Behind in Writing Notes

Let me tell you a story, the story of the typical therapist who comes to me saying they are behind in notes and desperate for help... 

We'll call our imaginary therapist Dorothy. Dorothy has been licensed for about two years and started her own private practice shortly after getting licensed. Before that she had a supervisor who would check in with her about clinical things and periodically about paperwork- just making sure it was done.

But now that Dorothy is the Owner of Oz Counseling she has a lot of other things on her mind besides client care and documentation... she attends networking events regularly with the hopes of growing her connections, makes sure to answer phone calls from potential clients, does her bookkeeping (as regularly as she can), decorates her office, works on her website ("that new picture will hopefully make a difference this time") and does about a hundred other things that take up time!

Ultimately, being a good therapist is what's most important to Dorothy. She's good at it and her practice is slowly growing as a result. But all the demands on her time have impacted one thing pretty significantly. She is getting behind in her notes.

Dorothy would never just NOT write notes so she does what lots of other therapists do but never talk about- she jots down quick notes to herself between or during sessions. 

These are just little notes on a steno pad but they remind her what was talked about in the session. Then she can go back and write the full note when she has time... tomorrow... or this weekend... or next week...

The pattern continues until Dorothy has about six months of notes on her steno pad and none in her client files. Now the task of writing those notes feels very overwhelming. She feels a sense of guilt and regret when continuing to take her quick notes on the steno pad.

But what other option does she have? She's so behind at this point. Better to have something than nothing, right? At least when she's able to finally sit down and write those notes it will go pretty smoothly because she has a backup.

Fast forward another month and Dorothy takes a day off seeing clients to start catching up on her notes. She looks at the stack and a huge sense of dread washes over her. This will take sooooo long! 

But she is brave and dives in anyway... and is devastated to find her brief notes she's been counting on aren't quite as clear six months later. She spends most of the time trying to connect the dots and make sense of what she wrote. After two hours she has barely made a dent in the workload and bursts into tears.

How could this happen? She was so sure she'd been making good notes for herself! Now she is scared. What if Tin Man requests his records next week? It would take days to get his notes ready. And Cowardly Lion is such a volatile client. What if something happens and someone wants to see his record?

She freaks out for a bit but then she goes to the all powerful internet to find some help. She types in "How to catch up on therapy notes" and finds... me!

Yes, I'm able to help her catch up (and that part is really important) but how do we know the pattern won't happen again? What was it that led Dorothy down this road?

Like my reference there? ;)

After working with dozens of therapists who struggle with getting documentation done on time I've discovered that time management with paperwork is largely dependent on the emotional connection the therapist has to the paperwork.

It's interesting to me that almost every therapist I've helped to catch up on months of notes has taken these quick notes religiously. So they are writing notes (not ethically sufficient to be considered in the client record but still notes), but think they're not. 

That leads me to believe this whole note writing thing is largely a mental game. 

Then I hear stories of counselors being berated by supervisors for poor documentation... but not being told what good documentation looks like. And I hear therapists say they never received any training in writing notes. They've just been winging it most of their career and assume it's okay.

Put all that together with the fact that most of us have insecurities around running our practice, feel guilty charging people for our time, and often burn ourselves out caring not only for clients but also for everyone else in our life. 

Yeah... recipe for disaster. 

So how do we fix it? By doing what we would tell our clients to do. We look at the cause of this issue with writing notes... then we create a plan of action and learn tools to make things work.

And we forgive ourselves for prior mistakes. We focus on loving ourselves, healing the relationship and changing our behavior for the better. 

Last year I created a training video to help therapists with this task of catching up on notes. I only offered it to those who were signed up for my email list but now I want to share it with you, because I think this is really important and I know this will help.

But promise me that you'll spend some time (even just 10 minutes) thinking about why you're behind on your notes before going to the action plan. Because if you don't take that time you'll just end up bookmarking the action plan to use every 6-9 months. 

I'd rather you create a whole new relationship with your documentation so that it's not something you're avoiding or dreading. 

Now do something that will truly change your life by taking that time and then let us know in the comments below. What keeps you from getting your notes done?

Then click here to watch the free video (and ignore the registration deadline at the end of the video). 

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

How to Start a Consultation Group

We're finishing up this "How To" series with something that can help you for the life of your career, starting a consultation group. 

Now, obviously I'm going to put a documentation spin on things (because that's why you're reading my blog!) but I've also got tips that apply to any clinical consultation group.

Not only am I the Documentation Diva but I'm also a supervisor and trainer. So I've collected some pretty awesome strategies for stretching your clinical muscles over the years. 

Getting the Group Started

There are two main ways to get your group started from scratch. The method you choose will likely depend on the purpose of your group and your particular clinical needs. First, identify what those are by answering these questions:

"What is our main purpose and our long-term vision?"

"Would various levels of experience work well with this group?"

"Are we focused on similar clientele, modalities or are we open to all types of treatment and specialties?"

"How many people would work well in this group and what is the limit?"

Now you have a place to start and can focus on one of the two main options below. But remember, a consultation group doesn't have to be limited geographically. You have many options for doing this group with others across the country (or the world!). Don't limit yourself.

  1. Start with a group of people you trust. Maybe you have a few colleagues that are already in the back of your mind as awesome people you trust and would love to meet with more officially. Easy, just shoot them an email or give them a call with your idea and bam! Consult group started!!
  2. Start with a topic of interest. Perhaps you don't have clear people in mind or are interested in focusing on something specific. In this case, you can reach out to a listserv, Facebook group or LinkedIn group to see who is also interested in your topic. If you go this route you'll want to have clear guidelines set up already so you can gauge who will be a good fit and try things out for a time. 

Now that your group is ready to go, I've got some ideas for what to actually do when you meet.  

Activities for Your Group

Below are 10 different activities for your new (or existing) consultation group. So if you decide to meet once a month you've got almost a year covered!

Identify the purpose of the group and the format. Your first meeting should clearly outline what is expected of everyone. You want to think about things like confidentiality, handling conflict, attendance expectations, method for accepting new members, who will take the lead and for how long, and how often you'll check in to see if the group is still meeting everyone's needs.

Do mock therapy sessions with one another, especially if you're focused on a particular modality or clientele. Remember how terrifying this was in grad school? Because we didn't know what the heck we were doing! It's just as important to do as we become more experienced. And it's a great way to get feedback on your own clinical style as well as pick up some new tips.

Write notes as a group. You can either do a mock therapy session and write notes based on that or someone in the group can describe a situation about which to write notes. I recommend you take 5-10 minutes for everyone to write individually and then (be brave) and share together. It's awesome to see the different styles but I guarantee you'll also be surprised to hear how similar the notes are... you just don't know because you never read anyone else's notes!

Present ethical dilemmas... like, your absolute scariest scenarios (or even the boring ones that happen all the time, like clients texting even when you told them not to). Maybe it's a story you read or heard from a colleague, maybe it's something that actually happened to you. The cool thing about ethical dilemmas is there's no black and white answer. And that's often where we find ourselves, walking in the grey areas. So bring it up and see what your colleagues are thinking!

Have an "intake day" where everyone brings in their intake forms and shares strategies with one another. You can pass the paper forms around and make comments for others while also taking some notes for yourself on ways to improve your own forms.

Train one another. Did someone just attend a really great conference? Maybe they can summarize some of the greater points in a handout or presentation. Have a topic you'd love to learn more about? Put something together and share it with the group.

Identify your clinical week. Have everyone share what their week looks like. You'd be amazed to hear the variety in schedules we all have. Perhaps you'll get an awesome tip from a colleague like Mari Lee, who takes every fifth week off from sessions.

Write a business plan. Many therapists have heard about business plans but feel intimidated actually writing one up. So do it together! Download a sample online and help one another through it. Share ideas and explain your plans to one another to get feedback. (You can read a great article on creating a business plan here)

Practice initial client phone calls. Similar to the mock therapy sessions, pretend to be an interested client and see how everyone does their initial screening calls. 

Watch a webinar or other training together and then discuss how it applies to you. I do monthly webinars and also have tons of trainings available if you're on my email list but you can also check out other things on topics of interest to your specific group.

Now the only thing left to do is to get out there and get started! Make sure you drop back over here to let us know how it's going. 

Looking for a little more structure and need help with your documentation? Check out my Meaningful Documentation Academy! This is the only time we're open for enrollment in 2016.

How To Review Your Own Notes

At this point I've talked with hundreds of therapists about one topic in particular- writing notes. And I hear some pretty common concerns...

"I feel like I always write too much but I don't know what parts to take out."

"I don't know if I'm including the right information."

"I feel like I spend too much time on writing notes."

Relate to any of these? I've found it's totally normal to have these concerns. And if you think about it, they make sense! 

If you're a licensed therapist you may never have another professional read your notes. Even if you're not licensed, I've found that most therapists receive very little training and review from their supervisors. 

While I do recommend connecting with other therapists to do chart reviews or at least discuss these issues (more on that in the next post), the quickest solution to this problem is knowing how to do a notes review yourself.

So let's break it down in a few easy steps:

Set aside an hour of time to review notes. Any more time and it will feel like a chore and make you overwhelmed but you want to include enough time to do a good review.

Start with one client file and go all the way back to that first intake note. Read through the notes chronologically from oldest to newest. Tip: If this is a long-term client, just go back the last six months or so. 

We'll start with each individual note first. Ask yourself the following questions with each note. I recommend having the questions in front of you so they're easier to remember:

  • Did I describe my own actions (or interventions) during the session?
  • Is my client’s response clear via quotes, observations or an assessment of what transpired?

  • Do I follow up on plans identified in each note?

After that is complete, answer the following questions about the entire file. The key is to make sure all the notes combine to make a clear story.

  • Do my notes provide a clear reason for my client initially entering treatment?     

  • Do my notes provide a clear story of this client’s progress over time?

  • Do I have a note for every date of service provided and explain gaps in treatment (like vacations or missed sessions)?

And there you go... you're now a quality assurance pro! 

I know it may be a little easier to have something in hand or on the screen to view, so I created a neat little handout you can download and print! Yup, you're welcome.

Click here to download your Notes Review Handout.

Your next question may be "But what if I find something is missing? How do I fix it?" Have no fear, the blog is here! Click here to read my article on fixing your notes after the fact.

Still looking for a little more help with your paperwork? Make sure you're signed up for my Love Your Paperwork Challenge**. It's two weeks of daily actions to make your paperwork awesome. And it's pretty epic, if I do say so myself. 

Please comment below and let me know if the Handout helped and share any other tips you have. Happy reviewing!

**This challenge is no longer current, but my Private Practice Paperwork Crash Course is full of tips and tricks that will help you rock your paperwork!