Before You Meet
These are the three questionnaires every client is sent before they meet.
PHQ-9
GAD-7
PCL-5
This document outlines steps for you and the client when they are struggling, and is a crucial part of the high-risk checklist.
Safety Plan
Where on the intake would a clinician write down that the client described a car accident that still causes flashbacks?
Trauma History
This is the first thing a therapist might ask at the start of an intake session or after reviewing practice policies.
“Can you tell me what brings you to therapy today?”
Every intake or progress note should begin with describing these two things.
Where client took the telehealth session and the duration of the session.
46 minutes for intake or 53-57 minutes for sessions.
This is what you do when you, a clinician, see that a client is set up for an intake in 24 hours and hasn't set up their client portal on Telehealth.
Send a reminder email or reminder text to the client.
If a client discloses suicidal ideation with plan, access, and intent, this is your next step.
Contact your supervisor immediately.
The section of the intake that a clinician would put down that a client reported daily panic attacks for the last 2 months.
History of Presenting Problem
This is the term for the main reason a client seeks therapy.
"The Presenting Problem"
It is best practice that every client has this on file for billing purposes before or by the end of the first intake.
A credit/debit card on file
The first policy element you should discuss before asking any private or personal questions of the client.
Confidentiality and Informed Consent
This part of the Mental Status Exam (MSE) describes whether the client is alert, oriented, or confused.
level of consciousness
You ask the client, “Do you like your current job? What did you do before?" and write the answers in this section.
Educational/Vocational History
What kind of question can you ask a client that might help them express their gender identity?
What pronouns would you like me to use?
or
Are there any other names you want me to use in session?
These three policies should be discussed in intake one, and they ensure clients know how often you’ll meet, how long sessions are, and how to cancel appointments.
Attendance Expectations
Cancellation Policy
Billing Policy
You get a client intake request on Zocdoc or Therapy notes, and this is what you should do.
Nothing! Admin will take care of it.
This area of the Mental Status Exam includes things like eye contact, motor activity, and grooming.
Appearance and behavior
Where the clinician would document the client saying "I’ve seen a therapist before, but didn’t feel heard."
Psychiatric History
You ask a client about their medications, and they tell you they take Lexapro 10mg daily, prescribed by their PCP. Where do you write this?
Hint: this section appears in every progress note. Bonus Question: What do you write in progress notes if the medication stays the same?
Current Medications
Bonus Answer:
You can use the history to keep the medications the same, or you can write "no changes" in that section.
Three options for whom you can seek support for questions you may have about practice policy, intake protocol, etc.
Your Supervisor
The Google Chats
Email department heads (i.e. Jamie, Jess, HP, Anna, Ashley)
This may get filled out before you meet, but it should be asked about in intake to confirm who you can also reach out to if a client needs extra support or is unresponsive and you are concerned.
An emergency contact.
This Mental Status Exam component assesses whether thoughts are logical, goal-directed, or disorganized.
Thought process
A client tells you that they grew up in a religiously conservative home, and their parents were very strict with them as a kid, which still impacts them today. What are the two sections a clinician should document this in?
Family History
Spiritual/Cultural Factors
This is the first entry on the intake after the Mental Status Exam and Risk Assessment.
What is the client's general identity, i.e., “gender identity, sexual orientation, race, religion, and other self-identifiers”
Who you reach out to if there is a problem with billing or a client's file, and you have spoke with the client already.
jessika@greenpointpsychotherapy.com
CC Billing@