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 to keep the client safe during a crisis.
Safety Plan
Where a clinician would write down that the client describes 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 this statement in the objective content.
The therapist and client met via telehealth for (53-57) minutes.
This is what you do when you see that a client is set up for an intake in 24 hours and hasn't set up their client portal on Telehealth.
Email the client if you haven't already to introduce yourself and/or send a reminder text about setting up their portal.
If a client endorses 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 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? This is where you write their answers.
Educational/Vocational History
How to handle a client's gender identity in intake.
Co-document and acknowledge the client’s identity and their pronouns in their chart.
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
Scheduling/Cancellation
Billing policies
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 MSE includes 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. Hint: this section appears in every progress note.
Current Medications
Three options for whom you can seek support for questions you may have about practice policy, intake protocol, etc.
Your Supervisor
The Google Chats
Supervision
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 in times of emergency or crisis.
An emergency contact
This MSE 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.
Billing@greenpointpsychotherapy
CC Jamie