Do you have the right forms?

Before you can see your first client you will need paperwork. If you are using an Electronic Medical Record (EMR) i.e. TheraNest, SimplePractice or TheraNotes, you may not need all the forms because these systems have the essential paperwork all ready for you to use. However, I would recommend if possible, to customize the forms to fit your particular practice and the State or local laws.

If you are not using these EMRs then you will need to create the forms for your business.  These are the forms I would recommend and what I use in my practice.

1. Welcome letter to the client. In this letter, I welcome the new client to the practice, confirm the appointment time and date as well as make sure they know which of our offices their appointment is in. Because my practice is a group practice, I also list their treating therapist and a little about them. I also list my direct contact information in case they have any questions or concerns. In all the years I have been doing this, I have only received 3 phone calls and those were easily handled.
2. Intake information. This form collects the demographics of the client and includes: full legal name, date of birth, address, phone, email, preferred method of contact, emergency contact, insurance information, occupation, marital status, ethnicity, preferred name, pronouns and a list of current concerns, health history and other items that you deem relevant. I also ask how did they hear of us or who was their referral source. Think marketing efforts.
3. Informed consent/consent to treat. This form explains the process of therapy, the risks, the benefits, alternatives to treatment, confidentiality; the exceptions, licensing status, education of the clinician and theories used. This form further discusses that therapy services are voluntary and the client directs them.  Our fees for services, insurance practices, the information that can release, who to speak to if there is a complaint and licensing board contact. Please check your particular states for more specifics. All 50 states have some form of written consent needed.
4. HIPAA policies. Is your business a covered entity or not? Additionally, this form explains how the business plans on using and disclosing the client’s protected health information (PHI), authorization needed to share health records, privacy rights, how to and where to direct complaints to HHS and your business.
5. Media Policies. Explain how your business uses email, texts and social media and what the limits are for each one. Remember to refer to the HIPAA guidelines.
6. Court Policy. This must be detailed in your paperwork how you handle court or attorney letters, requests for your appearance in court, the cost for these services and how you handle subpoenas. (Do not ignore them). I also include the possible negative consequences of the release of that information. For an easy cut and past court policy, please check out Nicol Stolar-Peterson, LCSW of Therapist Court Prep.
7. Credit card authorization. I keep a credit card in the file to change the co-pay or therapy session. This form has the signature of the client as well and all the credit card details
8. Payment receipt or Superbill. This is a receipt for payment by the client. A superbill is also a receipt of sorts that the client can use to ask their insurance company for reimbursement for paid services to you. A superbill is often used when you are not on or do not take the client’s insurance. Typically, the information on this form includes client name, address, diagnostic code, CPT code, your name, license and NPI numbers, amount charges and amount client paid. There should also be a disclaimer in your policies that you cannot guarantee if their insurance company will reimburse or the amount of the reimbursement. The client should always speak to their insurance company to verify reimbursement rates.
9. Intake, progress note and treatment plan. You will need to keep information on presenting problems, psychosocial and safety assessment, therapeutic intervention, the focus of each session, pertinent family or historical date and maybe a genogram. I include scales to make note writing easier and how you document must be up to care standards for your license. Create this paperwork once and use it for all cases.
10. 12-18 Informed consent. This is specific information for the teen population and it breaks down in easy to read language general practice information, confidentiality, emergency situation and how to contact the office.

We brand all our forms with the business name, logo, contact numbers and address. My team sends out this information through our client portal. However, before we had an EMR, we saved all these forms as fillable PDFs and emailed to the client via our HIPAA compliant email. A new client typically receives the paperwork within a few hours of scheduling an appointment. They can fill out the paperwork and send it back to us electronically or if they wished they could bring in the documents. We also have hard copies available in the office for those that didn’t like to use or have access to the electronic forms.

Remember to calendar a review of all forms yearly as laws and regulations change and you may want to add or delete forms to your packet.

If this seems too overwhelming or you simply do not have time to produce this.  I have a paperwork packet on Therapistbox.com that includes 16 forms from a welcome letter to a doctor’s referral letter. Click here to see all the forms. These forms can be customized to fit your practice in about 30 minutes of your time.