Assessment/Referral
Team that makes referrals based on the initial contact or intake assessment with new/prospective clients.
Who is the Admissions Team?
Due same day or at maximum within 24 hours of therapy session.
What are the therapy notes?
Document the treatment-related information that was addressed, as well as any identified practice areas and/or progress/areas of improvement discussed during a client's session.
What is the "Goals and objectives" section of the Clinical Services therapy note?
Teachers, School Counselors, Child Study Team Members
DCP&P caseworkers/supervisors (does not include NJ ABUSE hotline)
Probation, Court Systems, Legal Representatives
Outside Prescribers, Medical Providers
Family members who do not have guardianship of a minor client (relatives who may be assisting with the overall care of the minor or may be identified by the parents as having the ability to participate in and/or make decisions regarding the client's treatment)
What are some of the more common collaterals who we may require consent in order to communicate on behalf of the client/family?
Client's PHQ score has a decimal point.
When do you complete SAFE-T suicide risk assessment?
3 No-Shows within a 6-month window will result in a case being closed.
Client calls 24 hours prior to a scheduled session-document as "Write off/Cancel Session"
Client calls less than 24 hours prior to a scheduled session-document as "No Show" (Clients with private insurance will be required to pay a cancellation fee)
What is the Care Plus Attendance Policy?
Supervision requirement for provisionally licensed Clinicians (LSW, LAC, LAMFT).
What is individual or group supervision on a weekly basis?
Based on the outcome of the intake process, Admissions Counselor refers/links client to an Outpatient Clinician for individual/family therapy.
What is case assignment?
Completed collaboratively with the client/family during the initial session.
What is the initial treatment plan?
Specific, Measurable, Achievable, Relevant, and Time-Based
What are the components of SMART treatment goals and objectives?
Parent identifies that the child's (client) behavior has been impacting their academic and social functioning.
When to request consents to speak with client's school (counselor/CST/teacher)?
When to complete Auth to Release PHI from NJ School Sys to CPNJ v2 and Auth for PHI from CPNJ to NJ School Sys v3 under Consents?
One assessment that is completed during every therapy session.
What is a suicide risk assessment?
Successful completion of treatment goals and objectives.
Attends sessions consistently, but there has been no movement toward achieving goals/objectives over a period of time.
Chronic inconsistency/non-compliance with treatment.
Lost to contact.
What are some reasons that may support termination/discharge from treatment?
All Clinical Outpatient Clinicians (all license levels; full-time/part-time/per diem) are required to attend this meeting a monthly basis.
What is the Mandatory Administrative Meeting (MAM)?
Client describes experiencing a history of disordered eating during the Initial Comprehensive Assessment.
When would a Comprehensive Assessment Addendum-Eating Disorder v2 be required?
Treatment Plan Review (1st year of treatment); PHQ A/9; AUDIT; CRAFFT
What documentation is due every 90 days?
Completing documentation (i.e., therapy note, treatment plan) collaboratively with your client.
What is concurrent documentation?
Consent Log (external providers/entities); Care Coordination note (internal providers); Contact V2 (client/parent or legal guardian of minor)
What are three ways to document communication with other providers (internal and external)?
PESP
What is the Psychiatric Emergency Services Program?
Starting from the initial session with the client/family-the Clinician addresses one primary goal of therapy-which includes the client/family learning, practicing, and applying new skills to eventually grow confident enough to manage symptoms/life situations/stressors independent of therapy.
What is incorporating termination/preparation for discharge into the discussion with the clients from the beginning of treatment?
The number to call when there is a client crisis after business hours/during weekend business hours.
What is 201-466-0765?
A self administered tool used to monitor severity of depressive symptoms and risk factors over the course of treatment.
What is the PHQ A/9?
Deadline for the following documentation: Comprehensive Assessment Review and Health, Pain, and Nutrition Screen (HPN).
What is due on an annual basis?
Provides a snapshot of clinical measures, assessment follow ups, as well as identifies interventions that were used during the session.
What are "Other Activities"?
Frequency of care coordination between the Outpatient Clinician and internal providers when a client is dually or multiply enrolled in other CPNJ services/programs.
What is as needed, but on a minimum of once per month?
A Clinician is working with a family and has a suspicion of child abuse or neglect.
What type of concerns might result in the decision to call NJ ABUSE?
Client > Client Information > Enrollment Information
Where, in EVOLV, would you go to enroll, transfer, or discharge a client?
Clinical Services Administrative Support team to contact, in order to obtain client/parents signatures, when consent forms are completed via telehealth/remotely.
Who are Lorna Gazic, Program Coordinator and Karyn Mechan, Care Coordinator?
A tool used to screen adolescents for high-risk alcohol and other drug use disorders simultaneously.
What is the CRAFFT (CAR, RELAX, ALONE, FORGET, FRIENDS, TROUBLE)?
SharePoint document that organizes clinical documentation/workflow and protocols that are important for Outpatient Clinicians to competently perform their work responsibilities.
What is the Outpatient Clinician Manual?
Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), Motivational Interviewing (MI), Eye Movement Desensitization and Reprocessing (EMDR)
What are evidence-based practices?
Divorce Decree; Custody/Visitation Court Order; Legal Guardianship documentation; Appropriate Consent Forms
What are some of the legal documents that a Clinician would request from a parent/caregiver when working with a minor and parents are divorced/separated?
Contact a manager, call the hospital ER, alert PESP, call the chief of police in the town or residence
What are the steps required by a Clinician when a client presents with active suicide risk and is willing to voluntarily go to the hospital for further evaluation?
Treatment Goals Achieved, Lost to Contact, Client’s Request, Referred to More Appropriate Level of Care/Treatment Services
What are the four most common reasons a client terminates?
Primary contacts when clinical support is required.
Who are the Clinical managers/Clinical supervisors/ any member of the Clinical Services management team?
Based on presenting symptoms/identified needs, you determine that your client/client’s family can benefit from the services provided by another CPNJ program/department.
When do I complete the internal referral form in EVOLV and contact the program/provider to inform them of the referral via email and/or EVOLV alert?
Required forms when a client re-engages in therapy and the last comprehensive assessment was completed a year or more ago.
What are updated Consent Forms, Assessment/Screening Forms, Initial Comprehensive Assessment (Adult or Child), Intake Assessment Event?
Left message; Sent Letter; Rescheduled; Appointment to be Rescheduled; Refused Services; Enacted Emergency/Higher Level of Care
What are the new "No Show" options on the Clinical Services therapy note (whether this is a no show/no call or call in less 24 hours prior to scheduled session time)?
When a client is linked with a Care Plus prescriber, this documentation is used to show clinical collaboration between the Outpatient Clinician and the prescriber.
What are the treatment plan and care coordination notes?
A client has communicated an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim or victims, and the patient has the apparent intent and ability to carry out such a threat.
When does a mental health professionals have a "Duty to Warn"?
Document required when discharging a client.
What is the Aftercare planning v3 service event?
In the event of a client crisis (taking place after 5pm during the week or on the weekend) and the on-call manager does not answer your call-after waiting 10 minutes, you may seek assistance from this member of the management team.
Who is Melissa Oparaku, VP of Outpatient Services at 201-406-7679?
To be entered into a client's record when an ER visit or hospital stay is necessary (medical or psychiatric reasons).
What is a Placement Disruption?
Initial Call for Services-Intake Process-Referral/Linkage-Treatment Planning (Initial and timely reviews every 90 days during first year of treatment)-Provision of appropriate treatment interventions; On going assessment; Care Coordination with Supports/internal and external providers/outside entities; Practice/Applying Healthy Skills to make necessary changes; Treatment goal attainment; Discharge with or without additional resources/supports, as appropriate.
What does an ideal/successful treatment process look like?