Maelisa Hall, Psy.D. is a clinical psychologist who loves paperwork. We’ve been talking about her writing and article all about private practice paperwork. Please welcome her to the blog! -Joe
Starting Your Paperwork Off Right in Private Practice
By Maelisa Hall, Psy.D.
Starting up a counseling practice isn’t actually that difficult- maybe you pick a name, get a business license and open a business bank account, order some business cards, sub-lease from a colleague and get a phone number. You set up your website and an email account and you’re good to go (psst, if you want a serious breakdown of these steps, check out Joe’s video about starting a private practice here).
Lo and behold your first client schedules an appointment. Your excitement is suddenly overshadowed by terror- “Do I have all the right forms? Is it okay to email them the forms? What do I have to talk about in my first meeting with them? Does someone have some templates for me?”
Have no fear, this article is here… to help! Yes, there are some basic forms you’ll want at the ready prior to meeting clients. Some of these will depend on the specifics of your practice or even your clientele but we’ll review the basics. Let’s check them out a little more:
Consent for Services (some call this a Service Contract)
This form is crucial! Not all states require you have written consent but it is required that you document getting informed consent from your clients. I recommend having a form because it clearly outlines your guidelines. What do you include? That depends on your discipline and state guidelines but in general you want to cover the potential benefits and drawbacks of therapy as well as any limitations you have with confidentiality (for example, in California I am required to break confidentiality and report any suspected child, dependent adult or elder abuse along with various other things). Some therapists also include things such as expectations for contacting the therapist after hours, no show policy and fees. Regardless of what is in your form and whether or not it’s signed by the client, it is your responsibility to review these things with your clients and ensure they understand… and document in a note that you did so.
Notice of Privacy Practices
This form is required by federal law if you are a HIPAA-covered entity; however, it is also becoming a standard of practice, especially if you use an electronic practice management system. This form outlines your client’s rights to their protected health information, their right to have this information kept confidential, and possible limitations to that confidentiality. The idea here is that your client’s record is just that- their record, not yours. You as the therapist keep it updated and safe and make sure your clients know how you’re doing that.
Authorization to Release Information
In some circumstances you may work with other professionals (physician, previous therapist) to provide better treatment for your client. You may also work with a significant other (spouse, child, parent). Make sure to review with your client the limits to their confidentiality in these circumstances and have a release form that outlines to whom you’ll be speaking, for what purpose, and for what time frame.
Authorization for Credit Card Use
If you keep a credit card on file to charge your clients for no shows or any other reason, you’ll want to review that policy with them. This could be a separate form or part of your Services Contract.
Social Media Policy
Social media is pervasive and the likelihood of possible ethical conflicts is now inherent in our work as counselors. The best way to avoid confused boundaries or hurt feelings is to clearly outline your policy around things like having clients as “friends,” followers, and so on. Some have this as a separate policy and some include within their Services Contract. Either way, you want to review this with clients before it comes up as an issue.
The type of intake assessment you use depends on the services you provide, your treatment modality and your niche. For example, if you specialize in working with clients with chronic pain/illness, you likely want to have detailed questions related to medical history and contact information for the client’s primary care physician. If your specialty is counseling couples with a history of infidelity you’ll focus more on family history and couples-specific questions. However, if you provide psychoanalytic work with young adults you likely don’t need so much detail. The key is to make sure you collect enough information to provide appropriate treatment for each individual and refer to other specialists when necessary.
Treatment Plan Template
Ethically, you need a treatment plan for your clients but the format will depend on your specialty and orientation (and whether or not you bill to insurance). This could be a simple sentence or two in your progress note or it could be a one page template with goals, treatment recommendations and outcomes. The easiest thing to do is pick one way of doing treatment plans, adjust to your needs and then stick to it. This way you spend your time focusing on the clinical purpose of the plan and not how to format it for every client.
Progress Note Template
Progress notes are the lifeblood of your documentation as a mental health professional. Keep these notes short and sweet but don’t skimp on the important stuff like missed sessions, follow up after a high risk situation, and consultation with colleagues regarding ethical dilemmas. The phrase to remember here is “If it’s not written down, it didn’t happen!” I would again recommend using a consistent template (see how easy this stuff can be!). Choose a popular template such as DAP (Data, Assessment, Plan) or SOAP (Subjective, Objective, Assessment, Plan) and be sure documentation is part of your regular schedule so you stay up to date.
Don’t worry- everything doesn’t have to be perfect. Just get a template in the beginning and you can adjust it to your needs. Click here to check out Private Practice Paperwork Packet for ready-made templates. You can always make more changes later as your client’s needs change, laws/regulations change, or your preferences adjust. No need to get overwhelmed! Have any other tips for starting off your practice paperwork and policies the right way? Leave a comment and share with us.
Buy the Private Practice Paperwork Packet
Maelisa Hall, PsyD is a clinical psychologist who teaches therapists how to create rock solid documentation so they can spend more time with their clients and less time worrying about paperwork. She has a free Private Practice Paperwork Crash Course available here.
Photo by Sebastien Wiertz