As a therapist, you don’t need to spend hours creating your own forms to meet regulatory standards. I’ve already spent 1000’s of hours creating forms to meet Medicare’s highest standards -- 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.
Get Documentation Forms Preferred by Insurance Companies
Documentation Wizard TM Forms are not prefab templates limited to drop down menus, predefined answers, and limited space. Those types of templates are designed primarily for reimbursement purposes. They generally do not provide all prompts needed to justify medical necessity. Nor do they help you improve your clinical thinking. Documentation Wizard TM Forms satisfy all billing and clinical needs. They provide specific prompts for everything needed -- in a way that removes the guess work and the anxiety.
Once purchased, your forms can be downloaded to your computer immediately. But never worry about losing them because you always have access by logging back into your account.
You are free to customize these forms to suit your practice needs. They can also be uploaded into commonly used online systems.
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Become a Documentation Wizard
Essential Documentation from Intake to Discharge.
Recently updated to meet new Medicare guidelines
The DW Clinical Forms create and maintain the Golden Thread of documentation. They are designed around a simple formula that takes the guess work out of what and how much to write. They cue you to 1) include all the clinical content that helps you assess a client’s progress, 2) include the mandated insurance content, and 3) justify medical necessity. They are a combination of checkboxes and narratives developed so your clinical voice is present in each note. They can be customized to meet your clinical needs and stored in a paper file or your computer. They can also be uploaded to your digital program, or used to augment your online system.
Diagnostic Summary or Bio-Psycho-Social Assessment
The Golden Thread starts here. The Diagnostic Summary acts as the foundation for your treatment plan. A good one contains the information to help determine the prognosis of your client. The Diagnostic Summary includes:
- contact and emergency contact information
- religious/spiritual affiliation and meaning in client’s life
- education, work, and medical histories
- a culturally competent and inclusive trauma assessment
- birth/foster/adoptive family mental health history
- substance use history/inventory
- barriers to treatment
- reason client seeks services
- … and many other requirements.
Encourage your client to complete the Diagnostic Summary and bring or send prior to starting treatment. See how smooth the first interview can be and how it helps you determine a diagnosis.
Treatment Plan and the Treatment Plan Review
The Golden Thread continues by weaving a picture of the client’s problematic behaviors with hoped for goals, an assessment of prognosis and eventual progress. It delivers the criteria for justifying medical necessity and includes:
- presenting problem in behavioral terms
- barriers to treatment
- resources recommended
- duration and frequency of treatment
- … and many other requirements.
Once you write a Documentation Wizard TM Treatment Plan, you’ll feel confident that you can write a plan that is customized to your client, is clinically relevant, and can pass an audit.
Standard SOAP and DAP note templates can be vague, including ambiguous prompts like, “Clinical Content.” In the quest to be thorough, clinicians often write long stories with unnecessary content. Or they write too little afraid of providing confidential information. The result is wasted time and anxiety about the result. The Documentation Wizard TM Session Note leaves no stone unturned. It includes:
- start and stop time
- CPT Code
- telehealth protocol confirmations
- clarity on “clinical content”
- checkboxes for mini-mental status exam
- a thorough risk assessment
- a list of possible interventions with space to write a narrative
- a reminder to justify using 90837
- client’s response to treatment
- plan, progress, prognosis
- verification of medical necessity
- a way to explain veering from the treatment plan without rewriting before it’s due.
- … and many other requirements
The most frequently written document, session notes should be a snap to write. The Documentation Wizard TM Session Note takes the guess work out of what and how much to write.
Case/Collateral Consult Note
Writing case and collateral consult notes are critical to quality care. Whether you are at an IEP meeting for a child, working with a probation officer, or speaking with a former therapist, consult notes can help justify medical necessity and help protect you in case of a board complaint. The Golden Thread continues to weave through as the consult note shows that treatment is discussed and evaluated with others. This consultation notes includes:
- reason for consult
- start and stop time
- type of consult
- who’s present
- actions to be taken as a result of consult
- … and much more.
Protect yourself and your client by documenting your phone, video, and in person consultations.
The Golden Thread ends with the Discharge Summary. It’s an inclusive and specific review of treatment that reflects the treatment plan, verifies it ended and why. Neglecting to write a discharge summary can leave you open to legal issues and board complaints. The DW Discharge Summary includes:
- an inclusive and specific review of treatment that reflects the treatment plan
- reason for discharge
- condition at discharge
- follow-up recommendations
- confirmation that the client was notified
- … and much more.
Write a Discharge Summary that protects you from legal problems and supports your client in knowing what’s next for them.
PLUS, BONUS FORMS
- Real case examples of each form
- Explanation of how to write a Treatment Plan
- Extensive list of Barriers to Treatment
- Tips for Completing Authorizations and Phone Reviews
- Since starting anything new can be challenging, 3 weekly emails with tips on how to streamline the use your new forms.
Are Clinical Forms Compatible with Treatment Planning Books?
Clinical Forms may be used with or without a treatment planning book. The decision depends on your comfort using your own clinical voice as you represent the modalities you use in treatment. A treatment planning book is NOT included with this purchase.
Formatting of Clinical Forms
Clinical Forms are available as both Word Docs and Fillable PDFs. Both versions can be customized to meet your clinical needs and used in conjunction with many online systems. You get both with your purchase so you can try each to decide what works best for your practice.
Learn more about how to customize your forms and get your technical questions answered here: Technical FAQs
Become a Documentation Wizard
- 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.)
Every client must be given the Health Insurance Portability and Accountability Act to read.
- *Acknowledgment of HIPAA
Every client must sign the HIPAA to show they read it.
- *Insurance Information and Authorization
Information needed for insurance formatted to maximize the chances of being able to read it after the client fills it out.
- Receipt for Services (Superbill)
- *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 much more). Customize it to fit your practice needs.
- *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.
- *Office Policies (Consent to Treat)
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.
- *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
Enough said, other than it’s formatted to maximize the chances of being able to read it after the client fills it out.
- Case Closure, General
This letter includes reason for termination, a brief review of treatment, and referrals for continued treatment if necessary. Prove you communicated with your client that services were terminated, provide written closure and cover yourself legally.
- Case Closure Letter for No-shows
This letter includes a reminder of your no-show policy that the client signed at the beginning of treatment, an opportunity to have a final session, a date for termination if you do not hear from the client, a brief review of treatment goals, and referrals for treatment should the client need services in the future. Proving you communicated with your client that services were terminated and cover yourself legally should anything happen to the client.
- *Prescriber & PC Communication Letter.
Communicating 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.
- *Business Associate Agreement
If you have a 3rd party vendor (like someone who does your billing, cleans your office, or fixes a computer, etc. and has access to client information), you must have a Business Associates’ Agreement that reinforces HIPAA.
DIAGNOSTICS AND ASSESSMENT FORMS
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.
- 63 Standardized Assessments for Adults, Teens, and Children.
The is a list of free assessments by diagnosis with the links to each one.It includes multiple assessments for general quality of life, anxiety/panic, depression, mood disorders, OCD, PTSD, eating disorders, drugs and alcohol, attachment, personality disorders, disability, gambling, sex addiction, tobacco use, suicide risk, and compassion fatigue for clinicians.Insurance companies require us to administer standardized assessments because they are considered objective reports of client symptoms and therefore can help justify medical necessit
MASTER SUPERVISION & CONSULTATION FORMS
INTRODUCING Master Supervision & Consultation Forms exclusively for supervising therapist.
Though often referred to as the same, supervision and consultation are quite different and therefore have different needs. Supervision is provided to an unlicensed clinician. Consultation is provided by one licensed clinician to another licensed clinician. So I put together a set of Master Supervision Forms & Master Consultation Forms that outline the rights and responsibilities of each, along with templates for note taking. They are completely customizable in Microsoft Word format.
- Supervision Agreement
Supervision is much more than taking an unlicensed clinician “under your wing” to nurture their growth. You have specific responsibilities that hold legal liability. This agreement documents the rights and responsibilities of both the supervisee and the supervisor and the criteria for evaluating your supervisee. It provides a way for you to discuss and document how to handle potential disputes, how to interface with the agency of the supervisee, and more.
- Supervisee’s Learning Needs Assessment
Identifying your supervisee’s learning needs and styles at the beginning of the supervisory relationship is like collaborating on a professional bio/psycho/social assessment. It can provide a roadmap of the challenges and strengths that will need to be addressed so that your budding clinician has the best learning experience possible.
- Supervision Note
A good supervision template can inform your clinical thinking and keep track of your supervisee’s progress, just like a good session note does with a client. This template includes a list of supervision models, therapeutic modalities, topics and diagnoses discussed, and methods used so you can simply check them off. It also includes space for a narrative about the cases discussed and any comments worth recording about supervisee’s strengths, challenges, directive you may give, and more.
- Supervisee Evaluation
Without a blueprint for evaulation, there is no way to assess and document progress. This evaluation builds on the Supervisory Agreement and Learning Needs Assessment (like following The Golden Thread) so that together, you can track progress regarding clinical, cultural, and administrative competency, ethical practice, sensitivity to diverse populations, such as LBGTQ, and immigrants, and more. It includes a 15-item rating scale and plenty of space for narrative.
- Group Supervision Note
Documenting what happens in group supervision is just as important as documenting what happens in group therapy. The Group Sup Note lets you easily keep track of the model of supervision used, the therapeutic practices, topics, and diagnoses discussed, as well as the methods you used and modeled, and more.
- Consultation Agreement
When talking to another fully licensed clinician about a case, you are providing “consultation” to another professional, not supervision to a student. The responsibilities of being a consultant are vastly different than for a supervisee. This Consultation Agreement describes your professional responsibility, limits of responsibility, and legal liability.
- Consultation Note
Although a consultant is not legally responsible for their consultees, keeping notes on what you discuss is important because it 1) proves the clinician got consultation on a difficult case and 2) helps you, as the consultant remember the clients discussed, if ongoing consultation is needed. This template includes a list of the model and method of consultation used, a list of therapeutic modalities used, a list of topics and diagnoses discussed, and plenty of room for narrative note taking.
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.