Assessment
Can you bill for reviewing an assessment?
Yes
Whose responsibility is it that we have consents in the chart?
The managing clinician.
The number you put under social security if we do not have one on file/client does not have one
9999
How long should a safety related goal be sustained for?
2 months/8 weeks
This is when you complete a safety plan.
As soon as you find out about safety concerns (same day) i.e. self-harm, self-harm ideation, suicidal ideation, passive suicidal ideation, physical aggression, AWOLing, property destruction, animal abuse, homicidal ideation, pyromania, eating concerns (starving/binging/purging), and hallucinations/delusions.
What do you do when you see a referral in the assessment?
Support the family in getting connected to that referral and document.
Parents have never been married and no custody paperwork is in place. Who can consent for services?
Either parent. However, best practice is to get custody from both parents.
The differences between an AMR and PHI.
- PHI is to communicate with outside entities regarding client's mental health and/or to schedule appointments.
How long should a regular goal be sustained for?
2 weeks
Name 5 proactive interventions.
Deep breathing, grounding techniques, going to safe space, talking to a trusted person, listening to music, taking a walk, watching a favorite show/movie, for SATS cases calling on-call clinician, calling/texting 988 or some other crisis hotline, etc.
3 things you should do when school impairments are listed.
PHI for school, goals related to school impairments, and documented conversation.
When do you complete a caregiver affidavit?
- When no custody agreement is in place and 1 parent is unable to be contacted.
- When no guardianship is in place and neither parent is reachable.
How long do we have to release records when an AMR is completed?
5 days if requesting to inspect records.
10 days for summary report/letter.
15 calendar days for entire chart.
List 2 things to consider when formulating your goals to assure they are relevant to your client's needs.
By assuring they are related to their impairments and diagnosis.
Name 3 reactive interventions.
Calling 911, taking client to emergency room, calling Community Crisis Response Team (CCRT), taking client to Crisis Stabilization Center (CSU).
4 items that should be included in the presenting problem
Onset, frequency, duration, and intensity of symptoms. Custody status, current living situation, risk, medications, development of symptoms (i.e. triggering events), etc.
2 parents of a client are divorced and only 1 parent wants to consent for services and the other does not. Can we move forward with services?
No, unless the minor 12 years or older wants to self-consent.
List 4 records that can be released via the completion of an AMR.
Progress notes, summary letter, treatment goals, assessment, diagnosis, and psychiatric evaluation.
List 3 reasons why you would update treatment goals.
When client has met goals, client has made progress (when checking in at the 3 and 6 month mark), client has not made progress, the client/caregiver no longer wants to work on that goal, or the goal is no longer relevant.
List the steps to implement a lock box.
1. Identify safety concern (i.e. pills, sharps, etc.)
2. Review and update safety plan.
3. Talk to caregiver and client regarding current steps being taken to lock away items.
4. If steps are insufficient to assure client's safety, discuss with family implementing a lock box.
5. Ask your Program Supervisor for a lockbox.
6. Schedule time to go to client and caregiver's home to implement a lock box within 24-48 hours of obtaining a lock box.
7. Do a walk through of the house and sweep for unsafe objects with both client and caregiver.
8. Take safety plan and review with them.
9. Discuss how to use lock box i.e. as soon as an item is taken out and used it must be put back away immediately and discuss where lock box will be stored (outside of client's reach/access)
5 items in an assessment you should review.
What is diagnosis, treatment goals, treatment modalities, referrals, medications, risk(s), trauma history, custody, school impairments listed, medical history, etc.
List 3 appropriate forms of custody paperwork.
Legal guardianship, custody order, MAT order (LA County), SSSP consent paperwork (SB County), social worker consent paperwork (Riverside County).
List what to complete in a PHI.
What documentation/tasks need to be completed when updating treatment goals?
Plan development note, treatment goals in treatment goal tab, discontinuing old goals and marking progress in treatment goals tab, update CANS and PSC (6 month mark), and client tracker.
You're having a session with your client at their school. Your client reports having suicidal ideation with intent. What steps do you take?
1. Discuss with client how caregivers and school will need to be informed to assure their safety. If possible, trying to include client in these conversations.
2. Inform school (typically counselor or admin staff) regarding client's suicidal ideation with intent.
3. Wait at school while school takes their steps to address SI w/intent.
4. Check-in with caregiver once school has made their decision (safety plan and provide alternative suggestions if necessary)
5. Schedule follow-up appointment within 1 day.