Service Documentation & Records-Intake

Service Documentation & Records-Intake

The most important aspect of beginning counseling is to help the client feel comfortable and understand that the first couple of sessions are about getting to know them and their potential therapy treatment plan and goals.

Before typical psychotherapy sessions begin, it is required collecting the following information, which may be completed in sessions 1-3 depending on session flow:

Adult Intake Outline:

Part 1-General Information:

  • Introductions and helping the client feel comfortable
  • Contact and client demographic information
  • Billing and Insurance information (including copy of insurance cards if Office Manager absent)
  • Accepting payment/co-payment (if Office Manager absent)
  • Insurance documentation including subscriber information
  • General forms including limits of confidentiality – review and signatures
  • Release form(s)-if needed
  • Additional information in Theranest “Healthcare”

Part 2-Counseling Assessment:

  • Self Assessment
  • Initial Assessment and Diagnostic Codes-get as much information as you can

Part 3: Treatment Planning:

  • To be completed by end of 3rd session
  • Develop and review treatment plan with client
  • Schedule follow-up appointment(s)
  • Make any necessary referrals if needed
  • Relationship Wheel

Child/Adolescent Outline:

Part 1-General Information:

  • Introductions and helping the client feel comfortable
  • Contact and client demographic information
  • Billing and Insurance information (including copy of insurance cards if Office Manager absent)
  • Accepting payment/co-payment (if Office Manager absent)
  • Insurance documentation including subscriber information
  • General forms including limits of confidentiality – review and signatures.  Collect signatures of all parents if present, especially if splitting payment or sharing custody.  If 10 years of age and up, please encourage to sign documents as well
  • Release form(s)-if needed
  • Additional information in Theranest “Healthcare”

Part 2-Counseling Assessment:

  • If parents present, review limits of confidentiality for under or above 13 years of age
  • Meet with parents separately (with permission if 13 and older)
  • Initial Assessment and Diagnostic Codes-get as much information as you can
  • Parent Questionnaire
  • Meet with child/adolescent separately
  • Adolescent Questionnaire
  • Initial Assessment and Diagnostic Codes-get as much information as you can, diagnosis should be entered post intake appointment

Part 3: Treatment Planning:

  • To be completed by end of 3rd session
  • Develop treatment plan and review with client and/or parent input
  • Schedule follow-up appointment(s)
  • Make any necessary referrals if needed
  • Relationship Wheel (Child/Adolescent only)

Adolescent 13+ Outline:

Part 1-General Information:

  • Introductions and helping the client feel comfortable
  • Contact and client demographic information
  • Billing and Insurance information (including copy of insurance cards if Office Manager absent)
  • Accepting payment/co-payment (if Office Manager absent)
  • Insurance documentation including subscriber information
  • General forms including limits of confidentiality – review and signatures.  Collect signatures of all parents if present, especially if splitting payment or sharing custody.  If 10 years of age and up, please encourage to sign documents as well
  • Release form(s)-if needed
  • Additional information in Theranest “Healthcare”

Part 2-Counseling Assessment:

  • If parents present, review limits of confidentiality for  above 13 years of age
  • Self Assessment
  • Adolescent Questionnaire
  • Initial Assessment and Diagnostic Codes-get as much information as you can, diagnosis should be entered post intake appointment
  • Meet with parents separately (with permission if 13 and older)
  • Parent Questionnaire (with permission if 13 and older)

Part 3: Treatment Planning:

  • To be completed by end of 3rd session
  • Develop treatment plan and review with client and/or parent input
  • Schedule follow-up appointment(s)
  • Make any necessary referrals if needed
  • Relationship Wheel (Child/Adolescent only)

Couples:

Part 1-General Information:

  • Introductions and helping the clients feel comfortable
  • Contact and client(s) demographic information-have to pick 1 to be primary
  • Billing and Insurance information (including copy of insurance cards if Office Manager absent)
  • Accepting payment/co-payment (if Office Manager absent)
  • Insurance documentation including subscriber information
  • General forms including limits of confidentiality – review and signatures of both parties
  • Release form(s)-if needed, signed by both parties
  • Additional information in Theranest “Healthcare” if applicable

Part 2-Counseling Assessment:

  • Rule setting and session expectations
  • Initial Assessment and Diagnostic Codes-get as much information as you can
  • Referral to individual counseling if necessary
  • Brief individual meetings to discuss goals/expectations
  • Couples intake questionnaire, give to each person to complete

Part 3: Treatment Planning:

  • To be completed by end of 3rd session
  • Develop and review treatment plan with clients
  • Schedule follow-up appointment(s)
  • Make any necessary additional referrals if needed
  • Split 3 ways Relationship Wheel

Parent Coaching:

Part 1-General Information:

  • Introductions and helping the client(s) feel comfortable
  • Contact and client(s) demographic information-have to pick 1 to be primary
  • Billing and Insurance information (including copy of insurance cards if Office Manager absent)
  • Accepting payment/co-payment (if Office Manager absent)
  • Insurance documentation including subscriber information
  • General forms including limits of confidentiality – review and signatures.  Collect signatures of all parents if present, especially if splitting payment or sharing custody
  • Release form(s)-if needed
  • Additional information in Theranest “Healthcare” if applicable

Part 2-Counseling Assessment:

  • Initial Assessment and Diagnostic Codes-get as much information as you can, diagnosis should be entered post intake appointment
  • Parent and Child/Adolescent Questionnaires (put multiple children if necessary in the child questionnaire)
  • Parent Coaching Intake form

Part 3: Treatment Planning:

  • To be completed by end of 3rd session
  • Develop treatment plan and review with client and/or parent input
  • Schedule follow-up appointment(s)
  • Make any necessary referrals if needed
  • Relationship Wheel

PIP Program and Group Therapy: 

  • Follow curriculum outlines accordingly