Tag Archives: counselling session notes

The Essential Documentation Needed in Your Private Practice

Posted by: Andrea Cashman on March 10, 2014 4:39 pm

There are certain administrative requirements that are mandatory to operate your counselling private practice. These include documentation for client files such as a consent form for treatment, an intake form, session notes and payment receipts. I find these are the four that I use the most.

Writing session notes are essential because it is your professional and ethical duty to track the progress of your clients. It is up to you what to include in your notes. Keep it factual. If you were ever subpoened in a court case, chances are your notes will be. Personally, I make sure to write any treatment I have provided in addition to my assessment and observations of the client in session. A good format to try would be the SOAP format. I learnt this back in nursing school and it’s a great tool to use. SOAP stands for subjective, objective, assessment and (treatment) plan. Here is an example: http://www.ehow.com/how_6120666_write-case-notes-soap-format.html

An intake form is given to the client at the first session to fill out. It provides more information for the counsellor. It will be up to your discretion what you decide to include in your form; however, this is where research will help you decide. I think it is great to include client demographics, psychiatric and medical conditions, an emergency contact, previous counselling and what worked/didn’t work, who their GP is, their view of their presenting issue and what short and long term goals they would like to acheive in therapy.

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*The views expressed by our authors are personal opinions and do not necessarily reflect the views of the CCPA