The Clinical Documentation Sourcebook

The Clinical

Documentation

Sourcebook

Practice Planners? Series

Treatment Planners

The Complete Psychotherapy Treatment Planner

The Child & Adolescent Psychotherapy Treatment Planner

The Chemical Dependence Treatment Planner

The Continuum of Care Treatment Planner

The Couples Psychotherapy Treatment Planner

The Employee Assistance Treatment Planner

The Pastoral Counseling Treatment Planner

The Older Adult Psychotherapy Treatment Planner

The Behavioral Medicine Treatment Planner

Homework Planners

Brief Therapy Homework Planner

Brief Couples Therapy Homework Planner

Chemical Dependence Homework Planner

Child and Adolescent Homework Planner

Documentation Sourcebooks

Clinical Documentation Sourcebook

The Forensic Documentation Sourcebook

The Psychotherapy Documentation Primer

The Chemical Dependence Documentation Sourcebook

The Clinical Child Documentation Sourcebook

Couples & Family Clinical Documentation Sourcebook

The Clinical Documentation Sourcebook, Second Edition

The Clinical

Documentation

Sourcebook

A Comprehensive Collection of

Mental Health Practice Forms,

Handouts, and Records

Second Edition

Donald E. Wiger

PostScriptPicture

WILEY.EPS

John Wiley & Sons, Inc.

New York

?

Chichester

?

Weinheim

?

Brisbane

?

Singapore

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Toronto

This book is printed on acid-free paper.

Copyright ? 1999 by John Wiley & Sons, Inc. All rights reserved.

Published simultaneously in Canada.

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any

form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise,

except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without

either the prior written permission of the Publisher, or authorization through payment of the

appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA

01923, (978) 750-8400, fax (978) 750-4744. Requests to the Publisher for permission should be

addressed to the Permissions Department, John Wiley & Sons, Inc., 605 Third Avenue, New York,

NY 10158-0012, (212) 850-6011, fax (212) 850-6008, E-Mail: PERMREQ@.

This publication is designed to provide accurate and authoritative information in regard to the

subject matter covered. It is sold with the understanding that the publisher is not engaged in

rendering professional services. If legal, accounting, medical, psychological or any other expert

assistance is required, the services of a competent professional person should be sought.

Designations used by companies to distinguish their products are often claimed as trademarks.

In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in

initial capital or all capital letters. Readers, however, should contact the appropriate companies for

more complete information regarding trademarks and registration.

Diagnostic criteria taken from DSM-IV reprinted with permission from the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

Note about Photocopy Rights

The publisher grants purchasers permission to reproduce handouts from this book for professional use with

their clients.

Library of Congress Cataloging-in-Publication Data:

Wiger, Donald E., 1953¨C

The clinical documentation sourcebook : a comprehensive collection

of mental health practice forms, handouts, and records / by Donald E.

Wiger. ¡ª 2nd ed.

p.

cm. ¡ª (Practice planners series)

Accompanied by one computer disk.

ISBN 0-471-32692-5 (paper: alk. paper)

1. Psychiatry¡ªMedical records¡ªForms. 2. Mental health services¡ª

Medical records¡ªForms. I. Title. II. Series: Practice planners.

[DNLM: 1. Mental Health Services¡ªforms. 2. Documentation¡ª

methods¡ªforms. 3. Medical Records¡ªforms. WM 30W654c 1999]

RC455.2.M38W54

1999

616.89¡ä 0068¡ªdc21

DNLM/ DLC

for Library of Congress

98-38798

Printed in the United States of America.

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This second edition is dedicated to my loving wife, Debra.

There were so many times when I came home

from work exhausted from seeing clients, but still had to write

reports and then work on the book. You were always

there to say a kind word and rub my back. Thank you.

Let¡¯s go out to eat tonight. My mother will watch the children.

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