Intake forms, consent forms for counseling and psychotherapy and other forms that every therapist needs such as release of information, social medial policy as well as tips will be covered in this post. When you think about conducting psychotherapy there are many things to consider: the client, your theoretical approach, and billing, to name a few. One critical—yet often overlooked—part of counseling is the forms that you give to the patient at the beginning of counseling. The proper forms can set the tone and boundaries for successful treatment. Here is what you need to know about the forms you will want to give to your clients.
The intake form provides you the initial background on the client. Besides asking for basic demographic information, it may include past psychiatric treatment, medications, reasons for seeking therapy, and family history. Keep in mind that the intake form will be tailored for the type of counseling you perform, For example, a counselor that sees mainly couples will likely include questions about relationships, whereas a child therapist would focus on issues pertinent to children. The intake form acts as a first step for the areas that need to be addressed in treatment. Additionally, a therapist often has a large caseload and it can be difficult to remember everyone’s background. An intake form is a valuable resource that a clinician can refer to as a base of information about a particular client. Without it, you would be lost.
Consent for Services
This form outlines what a client should expect from therapy and the specific rules for your practice. It also takes into account the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for treatment, payment, and practice operations. More privacy information can be discussed in an additional form, as we will mention below. It is recommended that you discuss the following areas when using this form:
• The description of how therapy works, including assessment procedures and expected course of treatment.
• How to make and cancel appointments and how long those appointments will last.
• How much sessions cost and the fees assessed if clients cancel late or don’t show up.
• Is insurance accepted and how will insurance claims will be processed? It is also necessary to let a client know that insurance companies will require a diagnosis and want access to other personal information, such as a treatment plan. Additionally, it is critical to recognize that insurance reimbursement may be limited to a certain number of sessions.
• Appropriate ways to make contact with the therapist and emergency procedures.
• How records of treatment are kept and what is included in those records.
• Clients need to be informed that they have a right to their file but it is recommended that if they choose to see their record, that they discuss the contents with their therapist.
• If a therapist sees children, it is helpful to let parents know their role in treatment and what you will or will not be able to share with them regarding their child’s therapy.
Over the course of therapy, service-related questions will inevitably arise. This form goes a long way toward setting proper expectations and avoiding future confusion and conflict.
While some people may include privacy practices in the same form in which they describe their services, it is important enough to deserve its own form. Every state has its own rules about privacy and confidentiality, so you will need to check with your state licensing board for the specific laws. However, you can expect to talk about the rules of confidentiality and a client’s rights in therapy. It is especially important to discuss the limits of confidentiality, including instances where confidentiality must be broken, such as child abuse and self-harm. There is always a chance that confidentiality will need to be broken and it is best to be clear with the client from the beginning. Otherwise, they may claim they did not know and it will turn into a very difficult situation. For example, contacting Child Protective Services about an alleged abusive situation is much easier if parents were warned from the beginning that it could happen. Further, after reviewing this form, clients should know their rights to their information and how you plan to keep it safe.
Release of Information
This form permits therapists to share a client’s information with other people. Some therapists have clients sign a blanket release of information form at the beginning of treatment. Others do it as the need arises. Doing it at the intake stage gives you the flexibility to talk about the case as needed with other professionals. However, it is always a good idea to let the client know you are discussing their case with others as it occurs.
Social Media Policy
This is a form you are increasingly seeing in therapy practices due to the proliferation of social media. It is not uncommon for a therapist to have a personal or professional page on popular sites, such as Facebook, LinkedIn, or Twitter. The social media policy lets clients know how you will handle any social media interactions. Because of the need for strong boundaries in counseling, most therapists make clear that they will not respond to friend or fan requests or have interactions with clients on social media. As this form is not found as often in practices, here is an example.
Some Tips When Using Counseling Forms
• Having clients just sign the various forms is not enough. You need to make sure the client understands what they are signing. All forms need to be gone over verbally as well as have the client read them for themselves. This gives you a chance to clarify any areas of confusion or concern.
• Therapists may choose to merge many of these forms into one long document. It can be useful, however, to create separate forms to give them individual emphasis and make them stand out.
• Along those same lines, you will want to find a balance on your forms between providing too much detail or not enough. They need to be detailed enough to contain the crucial points but not so much that the client gets overwhelmed with information.
• Some clients may terminate treatment without warning due to concerns they have with the therapist, the practice, or basic privacy issues. To prevent this, it is important to reiterate to clients that they should first come to the therapist with any problems they may have about privacy or practice operations. Putting a line or two about that on the service consent form makes it more likely that the client will come to the therapist with their future worries.
Let’s face it, forms are a tedious—yet necessary—part of the counseling process. And you might be wondering how you are supposed to deal with forms now that you are performing therapy online? Luckily, EMRs are making it easier than ever for therapists to administer important forms to clients. TheraPlatform (EHR and telehealth in one software), for example, allows clinicians to send clients relevant documents for their online review and enables them to fill them out, sign, and return them electronically. With just a few clicks of the keyboard, the forms are completed. And you no longer have to worry about illegible handwriting. Therapists need clients to complete specific forms to uphold the integrity of the counseling process. With the advancements in virtual therapy, it no longer has to be such a daunting task. You can test drive TheraPlatform for free for 30 days and no credit card is required. Their plans are very affordable and their built- in telehealth is free while other EMRs charge additional fees for each provider. Sign up for a free trial here.
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