Who's Who
What are the 3 main types of billable therapeutic sessions that are provided by the therapist?
Individual, collateral and family therapy sessions. Other non-billable services include outreach calls to schedule sessions and/or coordinate care with collaterals, documented as a CM note.
Where can you find the panic button in your office?
Under each desk on either the right- or left-hand side. Most common on the right side.
How often should clients be scheduled for therapy sessions?
Once per week, or as clinically indicated. Any recommended changes in frequency should be discussed in clinical supervision.
Client went up to the roof of their building with intent to jump off and kill themselves. They were on the edge of the roof. Their sister pulled them back from the edge and brought them back into their apartment.
Reportable as a suicide attempt.
When should progress notes be completed?
No later than 24-48 hours after the date of service., and ideally concurrently! Use your IMA To-do list and weekly reports to keep track of your work. Notes are considered late after 4 days from the service.
What is the difference between a NYPCC Case Manager and a NYPCC Care Coordinator?
Case Managers assign clients to therapists (schedule ADM/VAM). They also receive client referrals, schedule intake appointments, outreach ADM NSs, and assist with referrals to other providers when needed. Care Coordinators assist clients with practical needs and referrals, such as housing, medical, and public assistance.
If there is a safety concern with your client, while on-site, and 911 is activated, who should be notified?
Your supervisor should be notified of any safety concerns as they occur within session. For on-site crises, inform front desk staff that 911 was called so they can direct EMS to your office, or the location of the emergency.
What is the minimum frequency of collateral participation in treatment?
At least one collateral session per month for all clients under the age of 18. One exception is that a child who is a parent is treated as an adult.
The client took 10 Tylenol with hopes to die.
Reportable as a suicide attempt. The action taken while having S/I constitutes an attempt.
What are the 4 primary IMA write templates therapists use?
Individual, Collateral, family, and No-show are the primary templates used, but there are also templates for case management and crisis notes.
Who is/are your clinic's director(s)?
Trainer to confirm the correct answer! Review the current Program Director and Assistant Program Director(s) for each clinic location of the new therapist cohort.
True or false: You can hang up the video call or end session if 911 has been contacted.
False. Do not leave the recipient alone. A clinical staff member must be with the recipient at all times, physically or virtually (phone/video), unless the recipient is threatening or acting in a manner that places the staff in immediate danger. If a virtual session is disconnected, attempt to contact the recipient by telephone to re-engage.
After a missed session, what steps should be taken?
For ADM/VAM, mark the appointment as "No-show" in IMA, then the Engagement team will provide outreach.
For clients already admitted to the clinic, follow the no-show procedures:
1. Outreach the client via phone within the first 10 min of the scheduled time in an attempt to start the session. If the client does not respond, leave a message to reschedule.
2. If the client does not respond after 48 hours, provide additional phone outreach and send a Missed Session letter, then consult with your supervisor for next steps. *If high risk, outreach within 24 hours and consult with Supervisor as needed.
Client reports suicidal ideation, with plan to ingest pills over the weekend.
Not reportable. The plan is concerning and 911/EMS referral is warranted, but an attempt has not yet been made so an incident report is not needed.
What is the best practice for timely documentation?
Concurrent/Collaborative Documentation. We have a training on this!
What is the difference between a Clinical Supervisor and an NYPCC Training Specialist?
Clinical supervisors oversee the clinical aspects of your work with clients, conduct regular supervision meetings and provide caseload oversight.
Training specialists conduct Onboarding Trainings, review clinical documentation during the initial training period, and assist with procedural questions regarding IMA and clinical documentation.
Who can you call on ring-central if your supervisor is not available for a clinical concern?
Supervisor's Line on Ring Central.
Jackson Height & Bronx: x11127
Bushwick: x11130
Linden: x11131
What is the easiest way to ensure that clients are scheduled consistently?
Schedule the client's next appointment at the end of each session. If the client misses a session provide outreach and document your outreach attempts in a CM note.
12 year old client discloses that she's been cutting her arm, wrists and legs with razors with no suicidal intent.
Not reportable. Ask the client to show or describe the cuts in order to assess the need for medical attention. Inform your supervisor, collaborate with collateral, update the safety plan and consider possible referral to psych ER if clinically indicated.
Is VAM a billable service that I can write a progress note for?
No! A VAM is not a billable activity code so DO NOT WRITE YOUR NOTE until the client is admitted via Clerical Request form and your calendar appointment is converted to a V30 and checked-in, after which you will be able to document the billable progress note in IMA and save unsigned as a V30/V45/VCO.
Who do you contact if you want to contact prescribers or share a prescriber related concern?
Therapists should contact Romayra Pollack (RPollack@nypcc.org) or Amanda Gaffney (AGaffney@nypcc.org) via email and include the client ID number as well as relevant details regarding the clinical concern. Your supervisor should also be copied (cc’d) on this communication.
Give an example of when you would use a SAFE-T assessment and when you would use a Violence Risk Assessment (VRA).
A SAFE-T assessment is completed when a client reports suicidal ideation and requires additional assessment to determine SI with intent/method/plan. This would also be completed if a client discloses a history of suicide attempts or self-injurious behavior that was not previously noted in treatment. The client does not need to have active SI for this to be completed.
A VRA is completed when a client discloses violent or aggressive behavior that requires additional assessment.
Show us how to schedule recurrent lunch or supervision appointments.
Calendar > Copy > Add member > Include all dates > Copy
Remember that client appointments must be scheduled and verbally confirmed by the client each week, so the copy feature should not be used.
15 year old client is missing, as reported by the guardian, and they were last seen by you for an in-person therapy session at the NYPCC clinic.
Reportable. Any significant incidents that happen on-site require an incident report, including a client who is missing. Review the Incident Report form and training materials for guidance.
If you do not check in your client, you can not _____.
Write the progress note. Remember to update the status of all scheduled appointments daily as either checked-in or no-show.