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Documenting Medical Necessity for Psychotherapists

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ethics

Informed Consent

August 3, 2025

The Informed Consent Conversation: Building Trust, Setting Boundaries, and Getting Paid Without Guilt

Getting paid without guilt starts before your first session even begins. Most therapists treat informed consent like annoying paperwork to get through before the “real work” of therapy begins.  But informed consent is not a signature. It’s a process. Done well, it protects your clients, … [Read more...] about The Informed Consent Conversation: Building Trust, Setting Boundaries, and Getting Paid Without Guilt

Documenting Mental Health boundaries,  Client Privacy,  ethics,  informed consent,  payment

AI in Psychotherapy with young therapist working on her notes in front of computer

July 29, 2025

AI in Psychotherapy: Disclosure or Consent?

Let’s break down the gray areas of using Artificial Intelligence that may keep you up at night. Like many therapists, you're thinking about using Artificial Intelligence (AI) tools in your practice or are already using them. And you're wondering what you need to tell your clients about how you use … [Read more...] about AI in Psychotherapy: Disclosure or Consent?

Documenting Mental Health AI,  disclosure,  ethics,  HIPAA,  Technology in Therapy

Essential Admin Forms for Therapists to Protect Your Therapy Practice

January 30, 2025

Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected

Private practice therapists juggle multiple roles – clinician, business owner, and administrator. But just like progress notes and treatment plans, running a private practice wasn’t taught in grad school. From clinical to legal and ethical issues to marketing and billing, the workload can be … [Read more...] about Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected

Clinical Documentation admin forms,  ethics,  legal,  paperwork,  private practice

Crisis Intervention green typewriter with the word "crisis" typed on a piece of paper, header for documenting crisis management by Beth Rontal, Documentation Wizard

August 17, 2024

Documenting Crisis Management – HELP!

From Chaos to Calm: Effective Crisis Intervention Strategies Naomi Golan, the creator of the Golan Model of Crisis Intervention (1978), describes a crisis as a person who faces a situation in which they feel so overwhelmed they go from a state of “balance to imbalance, and ultimately back … [Read more...] about Documenting Crisis Management – HELP!

Passing Audits crisis intervention,  documentation,  ethics,  risk assessment

treatment plan - mental health therapist - Documentation Wizard Beth Rontal

August 17, 2023

The Ethics of Other People Writing Your Treatment Plan

The Ethics of Other People Writing Your Treatment Plan QUESTION Is it ethical for one therapist to write a Treatment Plan for another therapist to use?  At my group practice, I’m often asked as a licensed therapist to do an Intake and write the Treatment Plan to hand off to a master’s … [Read more...] about The Ethics of Other People Writing Your Treatment Plan

Documenting Mental Health documentation standards,  ethics,  supervision,  treatment plans

Timely Progress Note Completion

July 6, 2023

Timely Progress Note Completion in Mental Health Documentation

The most frequently asked question I get in my documentation course is, “What is the deadline for progress note completion?  This is a frustrating question because like so many aspects of mental health, there is no definitive answer. Understanding the Confusion Our professional codes of … [Read more...] about Timely Progress Note Completion in Mental Health Documentation

Documenting Mental Health billing,  ethics,  medical necessity,  progress notes,  timely documentation

artificial intelligence AI for mental health clinical documentation

June 14, 2023

Can You Use AI for Mental Health Progress Notes?

Can You Use AI for Mental Health Progress Notes? Although AI has been around for quite a few years, it recently burst onto the scene like fireworks and is causing a lot of noise.  Some psychotherapists are already raving about how it cuts down on the time it takes to write their notes and … [Read more...] about Can You Use AI for Mental Health Progress Notes?

Documenting Mental Health AI,  confidentiality,  ethics,  progress notes

Alert!!

August 10, 2022

ALERT — CareDash and BetterHelp

Watch Your Back If you are a therapist, social worker, counselor, or psychologist, I’d like to call your attention to the fraudulent and unethical business practice of a company called CareDash. CareDash has created a directory of 1000s of therapists and your name might be on it. This may … [Read more...] about ALERT — CareDash and BetterHelp

Private Practice Therapy Client Privacy,  directories,  ethics,  reputation

why therapists need to be anti-racist

July 21, 2020

Why Therapists Need to Be Anti-Racist

Documentation Wizard stands in solidarity with those who are opposed to the senseless violence and oppression of Black people in this country.  As I witness the horrors of what is happening, I see how it is increasing people's sense of alienation, hopelessness, and helplessness. The 21st … [Read more...] about Why Therapists Need to Be Anti-Racist

Psychotherapist Notes anti-racism,  Cultural Competency,  ethics,  social justice,  systemic racism

couples counseling

May 17, 2016

How to Diagnose for Couple’s Counseling

Many couples presenting for couple’s counseling do not fit into a billable diagnostic category. How do I write a treatment plan and session notes -- or bill the insurance company if I don’t have a diagnosis? I’ve been getting a version of this question in my workshops, Misery or Mastery; Essential … [Read more...] about How to Diagnose for Couple’s Counseling

Documenting Mental Health adjustment disorder,  couple’s counseling,  diagnosis,  documentation,  ethics,  ICD-10,  medical necessity

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Recent Articles

  • Mental Health Documentation in an Uncertain World
  • Why Your Mental Status Exam Needs a Cultural Lens (And How to Add One)
  • The Informed Consent Conversation: Building Trust, Setting Boundaries, and Getting Paid Without Guilt

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