As a private practice therapist, you don’t need to spend hours creating your own forms to meet regulatory standards. I’ve already spent 1000’s of hour doing it for you -- and had them reviewed by an attorney to make sure they cue you to dot all the I’s and cross all the T’s.
Once purchased, you can download immediately them to your computer. But never worry about losing them because you always have access to them by logging back into your account.
Master Clinical Forms include essential clinical forms you need from Intake to Discharge. Customize them to suit your practice needs.
- Diagnostic or Intake Summary
Includes contact and emergency contact information, reason for seeking services, cultural issues, religious/spiritual affiliation, education, work, and medical histories, birth/foster/adoptive family mental health history, substance use history, barriers to treatment, client strengths and much more. Send the Diagnostic Summary to your client prior to the 1st session and see how smooth the first interview can be.
- Treatment Plan
Includes the Problems, Goals, Barriers to Treatment, Objectives, Interventions, Progress, Medications, resources recommended and much more.
- Session Note
Includes the start and stop time of each session, list of symptoms, mini mental status exam, risk assessment, interventions, objectives, progress and much more.
- Case/Collateral Consult Note
Includes reason for the consult, actions to be taken as a result of consult and much more.
- Discharge Summary
Includes a review of treatment, reason for discharge, condition at discharge and much more.
PLUS, BONUS FORMS to helpful tips on how to use these forms.
- Real case examples of each form
- Detailed explanation of how to write a Treatment Plan
- Extensive list of Barriers to Treatment
- Tips for Completing Outpatient Reviews or Authorizations
- Since starting anything new can be challenging, 3 weekly emails with tips on how to streamline the use your new forms.
Master Clinical Forms are available as both Word Docs and Fillable PDFs. Both versions can be customized to meet your clinical needs. Try each to decide what works for your practice.
Word Docs have the most flexibility in terms of being customizable and the “narrative” areas expand to meet your narrative needs. The downside is they can lose their formatting, but most people find them easy to use. I’ve had no complaints. They have less flexibility in terms of customization, but they will hold their formatting under all circumstances. If you are severely technically challenged, these may be the forms for you.
I also include static PDFs (non-fillable) if you’d like a pre-formatted version that may more easily print for you. This is a good solution if you do not use Microsoft WORD.
All forms have been created in Microsoft Word, which is the standard in word processing.
Because therapist who have taken my course and used my clinical forms asked, I delivered with a set of 16 Master Administrative Forms. They help streamline the practice of your practice. Created in Micro Soft Word, they are completely customizable (except for the HIPAA). Several of these forms have been written specifically for my practice (like office and social medial policies), but they provide the important items for you to consider. Please read them all carefully so you can modify them to your practice needs.
Send all the forms with an ‘*’ to your clients prior to their 1st appointment and see how quickly you can get through the “dreaded paperwork.”
- Intake Form
If you offer a screening call to potential clients, using this form covers all the bases. It includes reason client is seeking services, basic insurance information, a way to document a *fee adjustment if you offer one for private pay clients, and more. (*Documenting the rationale for a fee adjustment, formerly known as a “sliding scale,” is a legal issues. Please don’t forget to do it.)
- *Insurance Information and Consent to Treat Form
Without a Consent to Treat, you may not provide a person psychotherapy.
Every client must read and sign the Health Insurance Portability and Accountability Act
- *Acknowledgment of HIPAA
Every client must sign the HIPAA to show they read it.
- *Client Rights and Responsibilities
A mandatory form outlining what the therapist provides, the responsibilities of the client, their rights to fair treatment and the process of filing a complaint (and more).
- *Office Policies
If a problem arises and the solution or process or handling it is not in your office policy, you can’t enforce it. This includes a cancellation and inclement weather policy.
- *Social Media Policy
With widespread access to personal information, a social media policy is crucial. Not only may you not want your client to find out information about you, the client may not want you to find out information about them that they have not personally told you.
- *Release of Information
Clients must complete this so you can communicate with their medical providers or others involved in their treatment.
- *Credit Card Authorization Form
- Supervision Agreement
Supervision is a special relationship with an unlicensed clinician. As the supervisor, you have specific responsibilities and hold legal liability for the clinician you supervise. Document what you are and are not responsible for.
- Consultation Agreement
Consultation is for a licensed clinician. The responsibilities of being a consultant are different than for a supervisee. Have an clear agreement over how you provide consultation and its limits.
- Business Associate Agreement
If you have a 3rd party vendor (like someone who does your billing or fixes a computer that has client information), you must have a Business Associates’ Agreement.
- 3 Case Closure Letters
It may seem excessive, but you get 3 letters to address 3 different states of closure: concern for closure, a no-show letter, and a termination letter. Use 1 or all three. Prove you communicated with your client that services were terminated and cover yourself legally.
- Receipt for Services (Super Bill)
Use when a client wants to submit a bill to their insurance company for reimbursement.
- PCP and Prescriber Letter
Communicate with the PCP and Prescriber for continuity of care is important and necessary. This letter is a combination of check boxes and narratives that cue you to give the provider the information they need to be effective and for you to ask questions of the provider. Keep a copy in the client file to document that you have been in communication.
Because therapists who have taken my course and used my clinical and administrative forms asked, I put together a set of 4 MASTER DIAGNOSTIC & ASSESSMENT FORMS that help you get diagnosis in the 1st or 2nd session.
- 25 Item Symptom Checklist by Diagnosis
Have the client complete this checklist and bring it to the 1st session. Each diagnostic criterion has several questions for the client to check if the question applies. This helps the client report their symptoms in an organized way and focuses the diagnostic or first interview. See how quickly you can get a diagnosis and formulate treatment.
- 100 item Symptom Checklist by Diagnosis
This is similar to the 25-item checklist only it has questions for every criteria associated with the diagnosis. If the client seems to have a complicated presentation, use this form during the session/s for help understanding what you are seeing, to get a diagnosis and formulate treatment.
- Mini Mental Status Exam
You can find an extensive MSE online. However, I think they are were developed for new clinicians who do not know what to look for or how to document what they observe. This MSE is simple yet comprehensive MSE and all that’s needed for an adult.
- List of 63 free Standardized Assessments by diagnosis and the links to each one.
Insurance companies require us to administer standardized assessments because they are considered objective reports of client symptoms and therefore can help justify (or deny) medical necessity.
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These forms have been created for Medicare standards. Medicare standards are extremely thorough, and many insurance companies follow them exclusively. It is not possible to create forms that comply with all state standards. For state specific guidelines, you may want to review the National Academy for State Health Policy for medical necessity guidelines by state. https://nashp.org/medical-necessity/, particularly if you take Medicaid.