Attorney and Bioethicist Approved
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 clinical and practice management forms to meet Medicare’s highest standards -- and had them reviewed by three attorneys and a bioethicist to make sure they are the most thorough, ethical and requirement-driven forms available. These structured templates cue you to dot all the I’s and cross all the T’s.
Preferred by Insurance Companies and Ethics Boards
You didn’t learn documentation skills in grad school and neither did most of your mentors. The Documentation Wizard SM Forms do not perpetuate the confusion so many therapists experience because they are not passed down from one generous but untrained therapist to another like an unresolved legacy burden. Approved by three attorneys and a bioethicist, the Documentation Wizard Forms Packages meet all the requirements to pass audits and protect your professional integrity.
Always at Your Fingertips
Your purchased forms can be downloaded to your computer immediately. Never worry about losing your originals since they are always available by logging into your DW account.
You are free to customize these forms to suit your practice needs. They can also be uploaded or integrated into many commonly used practice management systems. Please check with your practice management provider for confirmation.
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Become a Documentation Wizard
Essential Documentation from Intake to Discharge.
Satisfies Medicare Regulations and Medical Necessity Guidelines
Developed to meet Medicare standards, the Documentation Wizard Clinical Forms initiate the Golden Thread with the Intake Summary and maintain it right through to the Discharge Summary.
The Documentation Clinical Forms provide a high level of structure not seen in other clinical forms.
DW Forms are not generic templates with limiting dropdown menus, predefined answers, or constrained by limited space. These types of templates are designed primarily for reimbursement purposes.
Because all the content needed has been distilled into discrete categories and sections, the formatting is deceivingly simple. For Example, there’s not one big box for “Clinical Content or another for “Assessment Comments,” leaving you to wonder what clinical content to include and what of the 6 assessments in a session note to address! The Documentation Wizard Clinical Forms provide prompts for all clinical content and assessments! This helps you create a cohesive narrative without telling the details of the story.
That took 1000s of hours of work. So, they are simple to use. But not simplistic. And they’ve been reviewed by three attorneys, countless clinicians, and a bioethicist with 2 thumbs up.
The Documentation Wizard Clinical Forms:
- include the mandated insurance content
- provide all the prompts necessary to justify medical necessity
- enhance your clinical thinking, protect client confidentiality and protect your income.
- include selective dropdown menus and checkboxes to assist with quick completion.
But that’s not all! The DW Clinical Forms:
- include all the clinical content that helps you assess a client’s progress, and
- provide space for short narratives where needed or required so your clinical voice and practice needs can and should be heard.
In other words, designed around a simple (but not simplistic) formula, the Documentation Wizard Clinical Forms take the guess work out of what and how much to write. They help reduce Documentation Anxiety!
The DW Clinical Forms can be customized to meet your clinical needs and stored in a paper file or on your computer. You may be able to upload the forms into your digital program or use them to augment your online system. Please check with your practice management system for confirmation.
What's New for 2024
Improved Ease of Usage & Consistency!
Every form is updated to the new and enhanced format!
New WORD docs offer a consistent presentation to make flowing from one form to the next in the Golden Thread clean and uncomplicated. The visuals on the forms are easier to read and even easier to fax. While we can’t promise you’ll enjoy writing your notes, we are doing everything we can to make it less of a chore with our bright and shiny new Clinical Forms.
- Updated and improved header! Data entered into the header on the first page will automatically duplicate on every page of that form! (This is a documentation requirement!)
- Header now includes space for insurance information including Payor and Member ID #. (This insurance information is required for some insurance companies. So, we added it to make sure everyone who needs it has it.)
- Additional checkbox prompts added with more ability to customize to your practice needs.
- Expanding narrative areas that start small and grow as needed.
- Incorporated the ability to add ordered lists to narrative areas.
- For the best results, we recommend using the most recent version of Microsoft Word in Microsoft 365.
The updated fillable PDFs include all the same attributes as the WORD Docs and a few more such as:
- Automatic phone number formatting
- Useful dropdowns for CPT Codes and Severity attributes that save time and reduce errors.
- The option to use a date picker for dates also enhances the ease-of-use for these forms.
- Checkboxes are incorporated to remind the user to answer often repeated responses such as risk assessment, modality, and severity.
- We recommend using the free Adobe Reader with the fillable PDF forms. Fillable PDFs will not work correctly if opened in a browser.
The fillable PDF format is static and does not expand for long narratives. The narrative spacing has been expanded to allow more room for narrative – but not too much. Based on Beth’s years of practice this space limitation reduces the temptation to write a book and reveal too much personal and confidential information. If you are significantly technically challenged, these may be the forms for you.
Intake Summary or Bio-Psycho-Social Assessment
The Golden Thread starts here. The Intake Summary (formally called 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 from a strengths based perspective. The Intake Summary includes:
- contact and emergency contact information
- religious/spiritual affiliation and its meaning in client’s life
- education, work, and medical histories
- a thorough mental health history
- possible legal involvement
- a culturally competent and inclusive trauma assessment
- birth/foster/adoptive family mental health history
- substance use history/inventory
- risk factors and barriers to treatment
- reason client seeks services
- client strengths
- … and many other requirements.
Encourage your client to complete the Intake Summary and bring or send it prior to starting treatment. See how smooth the first interview can be and how it helps you determine a diagnosis.
** New for 2024 **
The Reimagined Intake Summary Form (formerly the Diagnostic Summary) includes:
- Easy flow from basic personal information through medical history and trauma history
- Additional checkboxes and narrative sections to encourage improved responses from client
- Added a specific area at end of form for Therapist to Complete where you can add your own notes on client
- Comprehensive sections encouraging client to share current living situations including race, culture, ethnicity, religion, education, military service, vocational training, social clubs, legal issues, and even room for developmental history. While these sections are not new, they are now brought together in a more thoughtful and clearer manner.
Treatment Plan and the Treatment Plan Review
The Golden Thread continues by weaving a picture of the client’s problematic behaviors or “functional deficits” 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 (the required language of documentation)
- barriers to treatment
- clinical assessments
- risk assessment
- resources recommended
- duration and frequency of treatment
- the reasons for medical necessity
- … and many other requirements.
Once you write a Documentation Wizard Treatment Plan, you’ll feel confident that you can write a plan that is customized to your client, is clinically useful, and can pass an audit.
Standard SOAP and DAP note templates can be vague, including ambiguous prompts like, “Clinical Content” and “Clinical Assessment.” In the quest to be thorough, clinicians often write long stories with unnecessary content and redundant assessments. Or they write too little, afraid of revealing confidential information. The result is wasted time, potential lost income from an audit or board complaint, and anxiety about the process.
The Documentation Wizard Session Note provides a structured template that clarifies what and how much to write by breaking down clinical content and 6 different types of assessments into specific sections and naming them.
Because all the content needed has been distilled into discrete categories and sections, the formatting is deceivingly simple. For example, there’s not one big box for “Clinical Content" or another for “Assessment Comments,” leaving you to wonder what clinical content to include and what of the 6 assessments in a session note to address! The Documentation Wizard Clinical Forms provide prompts for all clinical content and assessments! This helps you create a cohesive narrative without telling the details of the story.
The Documentation Wizard Session Note leaves no stone unturned. It includes:
- start and stop times
- the diagnosis
- CPT Code dropdown menus that include family, crisis and add-on codes
- severity dropdown menus
- risk factors & barriers to treatment
- telehealth protocol confirmations
- specific sections to document the 6 areas of “clinical assessment”
- 47 checkboxes for a mental status exam and a way to customize them for your practice.
- 30 checkboxes of possible interventions and a way to customize them for your practice.
- space to write a short narrative to explain your interventions.
- checkboxes for a thorough risk assessment
- a reminder to justify using 90837 (if necessary)
- a reminder to justify a second session of the week (if necessary)
- client’s response to treatment
- plan, progress, prognosis
- verification of medical necessity
- a way to explain veering from the treatment plan without rewriting it before it’s due.
- a way to document no-shows and cancellations
- … and many other requirements
The most frequently written document, session notes should be a snap to write. The Documentation Wizard Session Note takes the guess work out of what and how much to write.
Case/Collateral Consult Note
The Golden Thread is enhanced by writing case and collateral consult notes. They are critical to quality care and demonstrating best practice. Whether you are at an IEP meeting for a child, working with a probation officer, or speaking with a prescriber or 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:
- date of consult
- start and stop time of consult
- reason for consult additional checkboxes
- who’s present and relationship to client
- 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 treatment has ended and why. Neglecting to write a discharge summary can leave you open to legal issues and board complaints. The Documentation Wizard 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.
Summary of Treatment
A Summary of Treatment can often be used in place of a treatment plan for situations other than an audit. For example, it can often be used in a request for a disability review, a Workman’s Comp claim, and is often used to satisfy a Risk Assessment Audit. A Summary of Treatment can be used when treatment information is needed and there is no risk of a recoupment. Take the struggle out of compliance with this Summary of Treatment template. It cues you to include all the required information in a logical step-by-step process.
In Addition to the Downloadable Forms, You Will Also Receive ...
- THREE SETS OF EXAMPLE FORMS:
- Example Forms for Case #1 – a real life example for a client with Major Depressive Disorder during the Pandemic.
- Example Forms for Case #2 – a real life example for a client with Binge Eating Disorder and a therapeutic breech.
- Example Forms for Case #3 - a real life example for a client with PTSD and legal involvement.
- Extensive list of Barriers to Treatment
- Tips for Completing Outpatient Reviews
- Video with Beth demonstrating how to complete a Session Note using a Fillable PDF (it’s like a mini documentation training!)
- Video with Beth demonstrating how to complete a Session Note using a Word Doc (it’s like a mini documentation training!)
- 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. For best results, we recommend using the most recent version of Microsoft Word in Microsoft 365 and Adobe Reader.
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.
The Administrative Forms were developed to satisfy a broad-based clinical practice. Please review all these forms thoroughly to make sure they represent your practice needs and your states regulations. You may make any changes needed other than the copyright.
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
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.