One of the “chores” of being in any sort of counseling or therapy practice, is keeping up with the documentation and paperwork. It can feel like riding a merry-go-round that just never stops! I have not met many, if any, practitioners that enjoys doing paperwork. Quite frankly, it just always seems to be a burden and no fun to do!
I know when I was working for a non-profit mental health organization that received funding from the state, the paperwork and documentation requirements just seemed enormous. How things were documented and the timeliness of that documentation determined how and when the organization got paid. The truth of the matter is, when dealing with any third party payers, how you document sessions determines how you get paid. At times though, if you are not careful, getting the paperwork done can become more important than serving the clients. It can almost seem like the job is the paperwork and seeing clients is a sideline job!
Paperwork doesn’t have to be a burden!
Paperwork and documentation can be a burden, but it does not have to be. Documentation, of course is necessary. Part of getting though the “documentation merry-go-round” is developing the right attitude about it. The other part of it is defining for your counseling practice the purpose of the paperwork so that it works for you rather than you working for it. For counselors in private practice, documentation can be much easier. The good news is that you get to decide how and what kind of documentation you want to use.
Private practice counselors and therapist do need to keep good records and stay on top of things in order to be successful. By having good systems in place and specific flow of paperwork helps you stay organized and efficient in running your practice. In fact, it is just good business practice to have a good paperwork system in place.
So what does good documentation look like for someone in private practice? Whether it is a solo practice or a group practice there are some basics and ways to organize and set-up your paperwork to make it work for you and be a valuable tool for your practice. So I think it is helpful to think about your documentation and paperwork as tools in your toolbox in the same way you think about therapeutic interventions as being tools.
Of course, making sure you have the right tools in your toolbox when the client comes is the first step. To make it easier for you, I have put together paperwork packet that is ready to be customized for your counseling practice. It contains over 20 different versions of forms to pick and choose from. But whether you use this packet of forms or create your own, you will want to make sure you include these basics or some form of them. How they look and how you use them will vary according to your style and your therapeutic approach. So let me describe these a little more:
Intake or Client Information Form
This form is simply used to get the basic information about your client at intake or when you start with them. It should include their contact information and some brief description about why they are coming to see you. It can be detailed, but does not have to be. I think this form can also be a way for you to track how they were referred to you and how they found out about you. I also get a little history and if there are any medical issues or medications they are taking; especially if they are taking any psychotropic medications. I ask about their doctor to know if there needs to be a coordination of care. Also there are questions about any safety concerns such as suicidal thoughts, etc. I also ask about their family and relationship status.
Consent for Treatment or Informed Consent
Some might refer to this form as being a “service contract”. This form is really a must. It is not only needed ethically, but some states require it legally. It should outline your agreement with client the scope and nature of their relationship with you and what they can expect from treatment. It should address confidentiality and what might the parameters of the confidentiality entails. For example, if they become suicidal or homicidal. It should cover expectations about coming to therapy and consequences for dropping out too soon or no showing. It may or may not include the fee agreement, but should probably state that there are fees for your services (unless you are giving them away). Essentially, this is the contract between you and your client.
This form is required by federal law if you are a HIPAA covered entity. This form outlines for the client how their personal health information (PHI) is kept and secured. It also outlines their rights to protected health information and rights to keep it confidential and the limitations to that confidentiality; such as sharing information with insurance companies, etc. In essence, the bottom line is that their records belong to them and you are protecting it for them. If you are using electronic records or a practice management system this is another form you must have. If you are not, it is still a good idea to have it.
Authorization for Release of Information
Social Media Policy (optional)
One of the ethical dilemmas of being in private practice as a counselor or therapist is how to find the balance between marketing on social media and keeping the boundaries for yourself and for confidentiality of the client. This form spells for your clients how you will handle “friends”, “likes” and “follows” on social media. Social media can create some “hurt feelings” if a therapist does not “friend” “follow” or “like” a client. So setting the boundaries on the front end helps eliminate this. You might include your Social Media policy in your “Consent for Treatment” form.
Fee Payment or Financial Form
This information might be covered in your Consent for Treatment, but I prefer to have a separate form for this. It is also useful and serves a dual purpose you are filling insurance claims for clients. The would give permission to file the claim and release PHI to insurance companies. The form also covers what the fees are for services and how they will be paid. It is really a separate contract that handles the financial end of things with your client. You might include in this form a credit authorization for you to charge their credit card for any no-shows or other fees that might come up.
Session or Progress Notes and Treatment Plans
I would say your progress or session notes are the back bone of your documentation. The treatment plan is just something that is ethically and professionally expected. The other forms covered above are a more or less one-time thing. But the session notes and treatment plans are something ongoing and essential to having good documentation. I prefer to have my treatment plan included as part of my session/progress notes. Others might want their treatment plan to be a separate document. Progress or Session Notes can be in any number of formats. Two of the most used progress note formats are SOAP (Subjective, Objective, Assessment and Plan) or DAP (Date, Assessment, Plan). Or you might come up with a note format of your own. The main thing though that you need to have in a progress or session notes is to tell when the session occurred and how long it was. And at the very least, the information in your notes should cover the mental status/assessment, presenting issues, and what you did in the session.
An easy and practical way to tackle progress and session notes is to have a template to use. I developed a template for Word called the Session Note Helper™ which provides a quick way to create a session narrative using drop-down menus of phrases to complete sentences. Like the full Paperwork Packet, it is customizable to your practice and can be expanded to meet your needs. You can certainly create your own templates and forms, however, I have done the work for you. I have put well over 40 hours into creating these forms.
If you are just starting out in private practice as a counselor or looking for ways to improve your current practice management processes, having the right paperwork can help you work smarter and take the “work” out of your paperwork!