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.

A consent form is written consent that your client should be signing at the beginning of therapy so that they understand what therapy is about and how you work. It is also good to write out the stipulations of your ethical/legal duties to breach confidentiality set out by the CCPA standards in accordance with the law. You may include your session details in terms of your session fees, cancellation fees, referral policies etc., I briefly go over the consent form with clients in the first session and refer back to the consent on an as needed basis.

There are other forms that are needed. These can include a release of information form which allows you, the counsellor, to connect with client’s health care s such as their GP with the client’s signed consent. Referral letters are a valuable documentation to have as you may need to refer clients to other therapists or third parties and a referral letter provides a brief summary of the client progress and the work that you have acheived in collaboration with your client. Of course, sending a referral letter will require client consent so a release of information form is required. A termination of therapy summary is  valuable to write after clients cease therapy and in order for you to close their file. Some  may choose to hand out to clients a client evaluation questionnaire to evaluate their progress as a therapist.

Good records help us remember client details and track client progress. Good record keeping  demonstrates our competency, decision making for clinical, ethical and legal options and provides rationals for treatment options. Make sure that your files are secured in a locked, secure filing cabinet. To assist you in developing your documents, refer to the CCPA’s standards of practice practice http://www.ccpa-accp.ca/en/standardsofpractice/  Best of luck in drafting your forms for your practice. Keep in mind that good records help counsellors provide professional and quality care to clients.
 

Andrea Cashman is a private practice counsellor who has founded Holistic Counselling Services for individual clients seeking therapy in Ottawa, ON. She also practices at the Ottawa Hospital as a registered nurse. Feel free to comment below or contact her at [email protected] or visit her website at www.holisticcounsellingservices.ca




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

6 comments on “The Essential Documentation Needed in Your Private Practice”

  1. Thanks for the nice, inspirational post.

  2. The documentation holds the therapist responsible to other specialists and, as previously stated, assists other therapists in providing care that is appropriate to the client. The documentation discusses risk control and recognizes relevant effects were observed.

  3. It’s an era of digitization where the big corporate and enterprise sector is heavily relying on data statistics , to understand the public behavior to gauge the performance and usability of some services and products and this is where data play its imperative role. great to know that

  4. Writer says:

    It’s really amazing that you’re sharing your experience and knowledge. Please keep doing this!

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