Paperwork is an inherent part of running a business, and mental health professionals need to ensure that their practice adheres to the right standards and best needs of their clients. With that said, documentation can feel overwhelming, and you certainly don't want to risk missing something crucial.
There are many different kinds of therapy forms, but the important takeaway is discerning what you must have for each client. In this article, we will review the main forms most therapists need in their practices. We'll also address some common questions newer therapists experience when onboarding new clients.
Crucial Forms For Your Therapy Practice
Whether you see clients in person or online, you must ensure that your practice maintains excellent documentation and adheres to all laws and ethics regarding client care. This is important for keeping your profession in good standing, but it’s also essential when navigating contentious issues like client confidentiality, insurance audits, and more.
Make sure your paperwork contains the following forms:
Informed consent: Your informed consent outlines the rules and expectations of your therapy process. It also outlines the nuances of confidentiality, the risks and benefits of therapy, and the client's rights in treatment. Clients deserve to make autonomous decisions about their healthcare treatment, and informed consent honors this need.
Office policies: Your office policy form should list the general housekeeping within your therapy services. These details include relevant information about your scheduling, fees, cancellation policy, and any other details about how you practice.
Assessment forms: Depending on what you treat in your practice, you may send assessment forms to assess symptoms of anxiety, depression, or other mental health concerns. These forms can be used in both individual and couples counseling, and they may be repeatedly completed throughout an episode of care to best track progress.
Good faith estimate: Mental health professionals in private practice need to administer good faith estimates to break down how much a client will pay out-of-pocket to work with you. It needs to contain the type of services rendered, your rate, and how much they can anticipate spending after a specific amount of sessions.
Credit card authorization form: This form contains your client's stored credit card information, so you can easily charge for sessions. It should include confirmation that they consent to being charged for therapy as well as their name, date, and signature.
Consent for telehealth consultation: This form must be signed before commencing any telehealth sessions. This form should include the client's name, date, and signature confirming they understand how to use your telehealth software.
Intake questionnaire: The intake questionnaire contains information about your client's medical history, mental health issues, and other important details relevant to your therapeutic process and treatment plan. These questionnaires typically ask questions about your client's relationships, family, career, medications, current substance use, suicide attempts or suicidal ideation, and previous experiences in therapy.
Closing summaries: Sometimes known as termination documents or termination summaries, these forms are completed after concluding a treatment episode. They should include your client's name, the date you began treatment, the date you ended termination, why treatment ended, and notes about the client's progress and overall prognosis.
Treatment plan: Your treatment plan focuses on the goals and interventions used within your therapy process. You will list what you intend to focus your sessions on, and this acts as a blueprint for guiding your therapy work.
Progress notes: Progress notes (also known as clinical notes) are legally and ethically required by all mental health licensing boards. It is often considered best practice to write notes as if a client could read them (as a client can always request access) or as if you could be subpoenaed by court. Keep in mind that you should separate any psychotherapy notes (notes for yourself) from these progress notes.
Authorization to release information: Also known as an ROI, this is required for exchanging information about your client with other individuals or providers. You need clients to sign this form if you plan to coordinate care with their family members, health insurance companies, primary care physicians, or anyone else on their treatment team.
Insurance verification form: If you accept insurance in your practice, this form is essential. The insurance verification form collects information about your client's health insurance, the nature of this protected health information, and all deductible and copay details.
When Should You Send Your Paperwork to Clients?
It's a good idea to send your paperwork before the first session when coordinating care with a new client. You want time to review these forms in advance to ensure the issues are within your scope of competence. You also want your client to understand the logistics of psychotherapy, including how payment works, how to access sessions, and what to expect when meeting with you.
That said, it's still important to verbally review paperwork at the onset of treatment. Make sure your clients understand the logistics of informed consent and verbally agree to meet your terms and conditions.
If you're managing a crisis, you may need to coordinate care, phone calls, and other treatment services before paperwork is completed. In most cases, this is acceptable, but you still want to ensure your clients are appropriately consenting to their care.
Where Can Mental Health Professionals Find Private Practice Paperwork?
Some people start with free templates when they first start their practice. While this can save you time and money upfront, it may be a costly mistake if you run into problems later on.
It may be a good idea to invest in a lawyer to review your documentation and ensure that everything is compliant. At the end of the day, it's your responsibility to adhere to state laws and keep your paperwork up-to-date. The DIY approach can work, but you risk making errors, and you absorb that liability.
How to Manage Your Paperwork and Streamline Your Practice
At Navix Health, we make it seamless to create, save, and share forms for your therapy practice. We understand that therapists are busy managing their caseloads and don't need a complicated EMR system that feels clunky to use. We also know that your time is precious, and we want you to focus on optimizing client care (rather than dealing with the hassles of documentation).
We value building a professional relationship with each of our clients. From the moment you meet with one of our representatives, you'll have peace of mind in knowing that we're here to support you and demystify your paperwork process from the very start.
Contact us today to schedule your complimentary demo!
