There’s nothing that brings more structure to your session than the boundaries you create with your personalized private practice forms. Immediately, the client knows who you are and what to expect, how much you charge and what you need to know about them. The ritual of form filling is as important as any part of your relationship with your client. Why?
It establishes you as a professional, it sets the rules of engagement and many times, allows the client to explain something they are not especially eager to discuss with a near-stranger.
For you, it keeps you HIPPA compliant and gets that pesky cancellation fee discussion started and in writing. A good Client History form often informs the path forward with a client that is ambivalent about the reason they are there in the first place. And a good Release of Information form is a way to triage with their other providers of care. This step often goes overlooked in our segmented medical culture.
Convinced? Good. If you need just one more reason—forms protect you against liability. Someday, when your practice is full, you won’t remember all the details pertaining to a particular client–information that can come in handy if they find themselves in circumstances that involves an attorney and a subpoena. A client of mine decided after many years of individual and marital therapy to pursue a divorce. It was long and contentious, and involved mud-slinging on both sides. I was happy to report to both attorneys the actual dates of treatment from beginning to end and how it was clear that our treatment dealt with a particular work issue not pertaining to the relationship and events that occurred later in the marriage.
Of course, I updated the release before my conversations and was able to bill for my time even though we had long before terminated. Why? It was stated clearly in my consent form that phone calls on his behalf would incur a charge!
Informed Consent: This must addresses all the elements of the therapeutic relationship including appointment details, format, fees, emergency procedures, communication (including technology), and license details.
Client Information Form: This should provide personal details including emergency contact, medical information, family of origin and psychosocial history. An objective or a reason for treatment may help to orient you and the client to a starting place.
Release of Information Form: The Release form is imperative for adolescent and children. It’s also extremely helpful to talk to previous or current providers of therapy or medical care.
Superbill or Receipt: Most clients will request something they can use for their insurance provider or Health Savings account. There are ready made Superbills easy to access on the internet. Google HCFA Form or Superbill and you’ll find something you can print out and use routinely. These are the generic forms accepted by most insurance providers. In the alternative, you can customize and print your own. Be sure that the most common DSM codes and CPT codes are included for easy check off. Be sure to have your professional license number with the state clearly identified.
Can we make it any easier? Well, yes. Go here to the resource page. Click on Practice Smart Forms. We’ve searched and these are the best out there. Complete, up-to-date and well researched for HIPPA, distance and telemental health and liability. All in one place for a great price. Enjoy!