What services do you see?
Therapist met with client to complete the quarterly assessments. Therapist and client discussed an upcoming court case related to client's previous sexual assault by a family member. Therapist and client revisited breathing techniques to implement during court when client has to face their perpetrator. Therapist and client role played and practiced client's victim impact statement.
Individual Counseling and Criminal Court Advocacy
Communicating with the foster care agency (referral source) about client's progress in therapy.
Advocacy or collateral?
Advocacy
Is it okay to complete a note without linking it to the client's CFP program engagement?
No! Always link notes to the client's program engagement.
What does OVS stand for?
Office of Victim Services
Therapist implemented EMDR techniques. Client disclosed suicidal ideation. Therapist supported client with creating a safety plan.
Individual counseling and crisis intervention.
Communicating with an ACS worker during their investigation due to brand new allegations of child sexual abuse.
Advocacy or Criminal Court Advocacy
Criminal Court Advocacy
A parent and child are both my client. I meet with the parent for their session and also take some time to discuss the child's progress. Who's profile should these go under?
The parent's session should be entered for the parent and the discussion of the child's progress should be entered for the child.
What "sections" should be completed in each note? What should be included/added in each note?
data, assessment, plan for next session
Progress Notes/Interventions, Assessment (Improvements, New Challenges, etc.), & Future Goals/Plans
Therapist implemented an activity that involved client painting their emotions with different paints. Therapist and client also discussed client's frustration related to becoming a U.S. citizen. Therapist signed client up for Sanctuary For Family legal clinic to gain a second opinion.
Art Therapy and Refer: Medical, Legal, Etc.
Met with client for weekly session to work on art therapy techniques. Attempted to complete the USF and client declined.
Art therapy OR Art therapy and Info Victim Rights
Art Therapy
Why do my notes need to be written in a timely manner?
For coordination/communication AND to make sure reports are accurate
What is a program engagement in Salesfore?
How we enter a client into a specific KHCC program.
Therapist called foster parent to confirm today's session. Foster parent stated they were unable to transport client due to recent surgery. Therapist called foster agency case worker to coordinate transport via foster agency vehicle for client to attend in person session.
Transportation Assistance
Zoom therapy session with client.
Individual counseling or individual teletherapy
Individual counseling
When DON'T we add services to note?
missed sessions, quick text for session reminders, attempt to reach rescheduled appointments, session not held due to therapist out sick, someone, termination or transfer summaries.
What does HIPPA stand for?
Health Insurance Portability and Accountability Act
Therapist completed the USF with client and when client disclosed food insecurity therapist provided details about KHCC's food pantry. Therapist also provided a gift card for Target so client could purchase some meat and fresh vegetables.
Info Victim Rights, Refer: Medical, Legal, Etc., Emergency Assistance
no note, note with no service, or advocacy.
Advocacy.
Add # of minutes per service and make a clear distinction in the note when each service begins.
Via the database request form