I. INTRODUCTION
UNCW General Psychotherapy & Assessment Clinic
POLICIES AND PROCEDURES MANUAL
2020-2021
LICENSED CLINICAL FACULTY
|Name |Cell |
|Dr. Berta Summers (Clinic Director) |919-672-1116 |
|Dr. Sally Mackain, (Director of Clinical Training) |910-231-9522 |
|Dr. Kate Nooner, (Graduate Coordinator) |973-873-8955 |
Table of Contents
INTRODUCTION 1
CLINIC STAFF 1
Director 1
Supervisors 1
Graduate Assistants 2
Graduate Therapists 2
CASE ASSIGNMENTS AND THERAPISTS' INITIAL RESPONSIBILITIES 2
Case Assignments for Individual Therapy Cases 2
Case Assignments for Assessment Cases 3
Court-Ordered Clients 3
Fee Determination 3
Cases Assigned from the Waiting List 3
Therapist’s Initial Contact with New Clients 3
OVERVIEW OF INTAKE CONTENT 4
REPORT WRITING POLICY 8
Treatment Plan Summaries 10
Case Closure Reports 11
Transfer Reports 12
Case Reopening 13
Contact Summaries 14
Intake Report Outline 14
Termination Report Outline 22
Monitoring of Files 25
PROGRESS NOTES 25
General Information 27
Communication w/Clients 28
GENERAL POLICIES & PROCEDURES 28
Policy on Exchange of Client Information within the Clinic 28
Release Forms Used When Communicating with Others outside the Clinic 29
Policies and Procedures for Releasing Client Information Outside the Clinic 29
Payment Deadlines 35
Insurance 35
EMERGENCIES 35
GENERAL INFORMATION 37
Hours of Operation 37
Vacation Policy and Practicum Periods 37
Website 37
Professional Behavior 37
Grievance Policy 39
Practicum Requirements 39
Weekly Therapist Activities 40
GENERAL TITANIUM GUIDE 42
Scheduling 42
INTRODUCTION
The GPAC is a training and service facility operated by the Department of Psychology at UNCW. Doctoral students in the general clinical psychology program complete at least two twelve-month practica in the GPAC. Supervision is provided by clinical psychology faculty. The GPAC provides comprehensive psychological services to adults in the Wilmington community and surrounding areas, to students attending UNCW, and to UNCW employees. The clinic is not a walk-in emergency facility; it is designed to provide emergency services only to current clients in crisis.
CLINIC STAFF
Director
Dr. Berta Summers is the clinic director; she is responsible for the operation and budget of the clinic and establishes operational policies and procedures. In conjunction with the clinical psychology faculty, Dr. Summers is then responsible for developing and implementing procedures that will lead to the attainment of clinical training goals for students. Dr. Summers is available to therapists when emergency situations arise (e.g., need for hospitalization) and she provides individual supervision and consultation about cases (e.g., watching therapy tapes) and professional development.
Supervisors
Currently, Dr. Summers (director) serves as the primary supervisor to students working in the clinic. However, other clinical psychology faculty supervise student therapists and have ultimate responsibility for the clients of their supervisees. Supervision teams are assigned by the director, with input from students and faculty.
In the event of an emergency, the licensed clinical faculty to contact include Drs. Summers, Mackain, and/or Nooner (cell phone numbers found on page 2).
Graduate Assistants
Each semester, graduate student assistants will be assigned to help with GPAC. They work closely with the clinic director to help implement and monitor clinic procedures, help with advertising and maintaining clinic social media. They will also be the first contact for prospective patients seeking services through GPAC (emails, phone screenings) and will facilitate case assignments.
Graduate Therapists
Starting in the summer following the first year of graduate school (moving into their second year), students will begin their practicum in the GPAC. First year students will be oriented to clinic procedures and assist with screenings. Second- and third-year graduate students in the general clinical psychology program are required to complete two twelve-month practica in the GPAC where they will provide psychotherapy and assessments. Graduate students can choose to continue their practicum experience at the clinic beyond the required 24 months in order to advance their clinical training. For any practicum training pursued at the clinic beyond the required two years, the student, the student’s major professor, and clinic director will collaboratively agree upon a caseload that meets the student’s training needs.
CASE ASSIGNMENTS AND THERAPISTS' INITIAL RESPONSIBILITIES
Case Assignments for Individual Therapy Cases
Potential clients call or email the clinic to request information about services. Graduate Assistants will monitor inquiries and respond to clients to gather initial information about their clinical needs (screening) and determine whether they should move on to an intake. The director reviews screenings and makes decisions regarding whether the case should move on to an intake assessment. Assignments are made based on the needs of the clients, the needs of the clinic, the skill level and interests of the therapists, and the stated preferences of supervisors in terms of the types of cases they are willing to supervise. Therapists who need a new therapy or assessment case should email the director to request assignment. If director assigns the case, the assigned clinician will conduct the intake evaluation to gather a richer understanding of the client’s needs. Click here for steps of new case assignment (e.g., how to access case information on Arcshare, email templates, etc.).
The information gathered during an intake (intake interview and SCID) will be used to gauge eligibility/fit for services at GPAC. Cases not accepted for services will be referred to other mental health facilities in the community (referrals given by the graduate assistants, student clinician, or the director). Applicants meeting the criteria specified below are typically referred elsewhere, although case-by-case exceptions may be made with approval of the clinic director:
• those with a psychotic spectrum or bipolar disorder who are not stable and/or are not taking psychotropic medications as needed
• if a current client decompensates to the point where they are not stable or adhering to necessary medications, they are referred elsewhere
• mandated and not motivated for treatment (in some cases, at the discretion of the director)
• custody evaluations
• UNCW psychology graduate students
Case Assignments for Assessment Cases
Potential clients call the clinic to ask for an evaluation (e.g., gifted, ADHD, learning disability). We do not currently offer Autism assessments. A running waitlist of interested clients will be maintained by the graduate assistants. When there are open cases, clients will be contacted to reassess their interest. Should they elect to participate in an assessment, they will be assigned immediately. Assessment packets including questionnaires of interest will be determined based on the presenting question and prepared in advance of the first intake for the individual to complete between sessions. In the event that a therapist chooses not to take an assessment case, they will not be offered another assessment case until each therapist in the clinic has had the opportunity to have an assessment case. Thus, if you need assessment hours, it is very important not to skip an assessment case when offered.
Court-Ordered Clients
The clinic is not currently accepting Court-Ordered Clients.
Fee Determination
The standard clinic therapy fee is $40 per hour, with reductions offered on a case-by-case basis (range of $10-40; reductions must be approved by director). However, during the COVID-19 pandemic, therapy fees are being temporarily waived. There is a separate schedule of fees for testing and evaluation (starting at $400).
Cases Assigned from the Waiting List
Clients are placed on a waiting list if for any reason they are unable to be assigned to a therapist immediately. The graduate assistants or director will make referrals to other agencies when the client is in need of treatment immediately or cannot wait for the length of time necessary to be assigned to a therapist.
Therapist’s Initial Contact with New Clients
When a case is assigned, the therapist must contact the client within two working days to schedule an initial appointment. If done via a phone conversation, the therapist should inform the client about: the specific fee for services; the length of the first and later sessions; the location of the clinic, if they have not been to it; the availability of parking spaces and permits; and the purposes and objectives of the first few sessions.
If a client has expressed any suicide risk in previous clinic contacts, the therapist should respond accordingly. Clients above low risk should be reassessed more frequently than other clients. This may include a reassessment during your initial phone contact with the client. Please refer suicide risk assessment procedures for details on how to assess suicide risk and how to handle clients at each risk level.
For assessment clients, the objectives of the sessions are to obtain background information relevant to the referral question and to administer instruments that will help the therapist answer the referral question. For therapy clients, some of the major objectives of the first few sessions are to:
1. obtain a thorough history and develop a diagnostic impression (e.g., by utilizing the Structured Clinical Interview for DSM-5 (SCID);
1. work with the client to identify specific therapeutic goals and;
1. discuss with the client whether the client wants to pursue the treatment plan outlined by the therapist.
Release of information forms (except for the emergency contact form) will generally not be found in a client's file at this point in time as these forms should not be completed and signed without a specific purpose; it is usually up to the therapist and client to determine if releasing and/or requesting information from others is warranted and appropriate.
OVERVIEW OF INTAKE CONTENT
Prior to intake, therapists should review any existing client information acquired during the screening interview and transfer relevant information to the clinic intake interview for the first sessions in order to reduce redundancies for clients. Intake sessions can be up to 1.5 hours (they may be shorter if the therapist determines that they will not need the full 1.5 hours), therapy sessions are fifty minutes, and testing sessions vary according to the purpose of testing and age of the client.
One of the purposes of the intake session is to gather information about the client's presenting problem and background so initial hypotheses about the client's problems can be formulated. For therapy cases, initial treatment goals and methods are determined on the basis of this information; for testing cases, the information is integrated with other data sources and recommendations relevant to the referral question are made. In addition, the session is used to determine whether the client can benefit from the services provided by the clinic. The session also serves to familiarize the client with the nature and policies of the clinic. Although intake sessions are primarily to gather information, this does not mean you should avoid therapeutic interactions as they frequently occur during intake. Elaboration of these points follows.
1. At the beginning of the intake session for therapy cases, the therapist should briefly reiterate the purposes and objectives of the first two sessions as outlined above.
1. At the beginning of the intake session, the following information about the clinic must be relayed to all clients:
• Therapist credentials. The therapist is a graduate student in clinical psychology working towards a Ph.D. in the Psychology Department at UNCW. The therapist should be sure to inform the client of the therapist’s full name.
• Supervision. The therapist is closely supervised by a psychologist on the faculty in the Psychology Department at UNCW. The client should be told the supervisor’s full name (e.g., Dr. Berta Summers).
• Confidentiality. Communications between the client and staff of the clinic are confidential, i.e., no information about the client will be released to anyone who is not a clinic staff member without the written consent of the client. However, under certain circumstances, the clinic is obligated to release information whether or not the client approves. The limits of confidentiality are stated below and should be briefly reviewed with clients.
o Suspected abuse of children, the elderly, and the disabled (physical, sexual, and neglect): As psychologists, we are required to report suspected abuse to the Department of Social Services.
New Hanover (County 65)
Director: Mary Beth Rubright
1650 Greenfield St., Wilmington, NC 28401
Phone: 910-798-3400
Fax Number: 910-798-7824
Emergency Phone: 911
CPS/APS: 910-798-3420
Medicaid Transportation: 910-798-3482
o Potential homicide and suicide, including the need to hospitalize someone because they are determined to be a threat to self or others.
o Court order issued by a judge: The director consults the university attorney in all such cases. Should you ever receive a subpoena or court order, you must immediately discuss this with the director before taking any action.
▪ The therapist should fully explain any release of information forms the client signs, including the potential consequences of releasing information to the identified individual, organization, or agency. The therapist should also ascertain whether the client understands what they consented to when signing clinic consent documents.
• Fees. The following information about fees should be given to clients when relevant to their particular situation.
o All therapy fees are due the day services are rendered. All testing fees are due upfront unless other arrangements have been made with the director.
o Phone contacts: Therapists' phone conversations with clients, or on behalf of clients, that last fifteen minutes or longer will be charged at a "real time" rate based on clients' therapy rates. For example, a thirty- minute phone conversation would be billed for .5 units of therapy. Assessment batteries include phone contacts as part of the flat fee for services.
o Therapy clients are charged at a real time rate for school and home visits (including therapists' driving time) based on clients' hourly therapy fees. These services are covered by assessment battery fees.
• Cancellations. Twenty-four hour notice is required for all cancellations. If shorter notice is given or clients do not show for their appointments, then therapy clients are charged their usual session fee; clients who are paying a flat fee for an assessment are charged $40 for each missed session.
• Insurance. We do not accept assignment of insurance benefits. Fees are due when services are rendered.
1. For therapy cases, a second or third session may be needed to gather sufficient information to generate hypotheses, determine treatment goals and methods, and to decide if the client is appropriate for treatment at the clinic. For testing cases, one session is generally sufficient for gathering background information. Only the first meeting with the client is technically considered an intake session and may be scheduled for 1.5 hours; all additional therapy sessions are scheduled for fifty minutes.
1. The decision of whether to continue therapy after the first few sessions or to refer the client elsewhere is made by the supervisor and therapist. The decision is made on the basis of the suitability of the case for training and the likelihood that the client can be helped at the clinic. The latter includes whether the client's needs fit with the training function of the clinic (e.g., does the client need the same therapist over a long period of time or extensive back up to deal with repeated crises?). A client does not have to be accepted for ongoing services at the clinic just because s/he was scheduled for an intake session. However, if a decision is made to refer a client elsewhere, it is the therapist's responsibility to help the client find a suitable referral and to maintain contact with the client until s/he has initiated contact elsewhere, preferably waiting to cease contact until s/he has been accepted as a client elsewhere.
5. Conducting an intake interview is essentially a tracking procedure, during which the therapist begins with the stated reason the applicant came to the clinic and then uses theory and experience to flesh out the etiology and severity of the problem, the conditions under which the problem is manifested, variables that may bode well or poorly for treatment, etc. During this process, of course, problems that the client did not mention on the application are likely to surface, and the same tracking procedure is used for these problems. Accordingly, information that is sought in the intake for one client will not necessarily be the same information that is sought for another.
REPORT WRITING POLICY
Report writing is a crucial part of the documentation process for your clients. All reports must be printed out, signed by both you and your supervisor, and filed in the client’s chart. Reports are not to be released to anyone (including the client) without a signed release of information form from the client. Importantly, when you are sending drafts of the report for your supervisor to review, the document must be password protected using the clinic password (will include year report written; e.g., “GPAC2020”). Reports are required to be written at the following stages of treatment (click on each type of report for more details about the report content and formatting):
|Type of Report |Final Report Due in Client Chart |
|Intake |2 weeks after the final intake session (Intake Report Outline) |
|Treatment Plan Summary |2 weeks from the six month mark after the intake report was filed, and every six months thereafter |
| |from the date of the last report |
|Case Closure |2 weeks after the final termination session/phone contact or the date specified in the phone message |
| |or letter (Termination Report) |
|Case Transfer |2 weeks after your final session with the client |
|Case Reopening |2 weeks after the updated intake information is gathered |
|Contact Summary |2 weeks after final attempted client contact |
NOTE: ALL REPORTS ARE TO BE ON CLINIC LETTERHEAD.
Reports should be completed in word and edited through email with your supervisor. Until the report is finished, it should remain deidentified and password protected. After the report is finished and signed, it should be uploaded into Titanium and attached to the appropriate progress note type. Make sure that the uploaded copy is signed and is NOT password protected.
Intake reports
A report must be written after completing intake with a therapy client. It is best to complete intake in one 90 minute session. If necessary, the gathering of intake information can be continued during one or two additional, 50 minute sessions.
A summary of the DSM-5 diagnoses and a measure of functioning (e.g., World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0) are required for every intake report. The reasons for diagnosis (and the reasons a diagnosis was not made) must always be included in the intake report. Any changes in the diagnoses during the course of treatment should be noted in the next written report (e.g., treatment plan summary, termination report). Provisional diagnoses made during the intake process should be confirmed or changed in subsequent reports.
Click here for an outline of the sections and content of an intake report [at end of this document].
All intake reports are due in their finalized form two weeks after the final intake session. All intake reports should have an “information box” as a header to the report, in the following format:
Intake Report
CONFIDENTIAL
|Name: Ima Client |Occupation: Accountant |
|Date of Birth: 08/03/90 |Marital Status: Single |
|Age: 30 |Dates of Interview: 08/04/20; 08/11/20 |
|Sex: Female |Date of Report: 08/23/20 |
|Race: African American |Therapist: Ima Therapist, M.A. |
|Education: Master’s |Supervisor: Berta J. Summers, Ph.D., HSPP |
Treatment Plan Summaries
These provide a brief periodic review of the client progress, therapy goals, means to achieve those goals, and treatment plan for the upcoming months. A summary needs to be written for each client who is in therapy. Treatment plan summaries are due two weeks from the six month mark after the intake report was filed, and every six months thereafter from the date of the last report. If the client terminates therapy before the end of a six-month interval, the case closure report will take the place of that interval’s summary. If you ever work in a setting that accepts client insurance, you would be required to submit a report of this nature every so many sessions (e.g., 10 or 12 sessions) to justify to the insurance agency the client’s continued need for services. The following should be included in the summary:
1. Number of sessions attended, missed, and/or cancelled either since the client began therapy (if this is the first treatment plan summary written) OR since the most recent Treatment Plan Summary (if a treatment plan summary was written six months prior). You may wish to note any changes in attendance patterns in the time since your last summary/report; e.g., "client was seen for 15 sessions and cancelled three 3 sessions without sufficient notice between January 6, 2020 and May 15, 2020."
2. Very briefly highlight the target areas of intervention (case conceptualization) and therapeutic approaches used. Note any changes in treatment approach since your last summary/report. The client's progress, including goals that have/have not been achieved should also be included.
3. State your treatment plan for the upcoming months, (e.g., The therapeutic approach will remain unchanged and continue as above in the upcoming months; The treatment plan will be adjusted in the upcoming months by implementing a predominantly behavior-focused approach to target the following problem areas).
4. Brief statement concerning how these treatment goals will be assessed (i.e., how will you monitor whether treatment goals are being met?).
5. List the current DSM-5 diagnoses and measure of functioning (e.g., WHODAS 2.0) at the end of the report. If there has been any change in the diagnoses, provide a brief rationale for the changes. If there is no change in diagnoses, simply state this in the last sentence of your report.
6. As an appendix to the report, include graphs of any symptom monitoring measures you have been administering throughout treatment.
Although this should not be the only time that therapists evaluate their clients' progress in therapy, the treatment plan summary provides an excellent opportunity to reassess their diagnostic decisions and treatment strategies.
All treatment plan summaries should have an “information box” as a header to the summary, in the following format:
Treatment Plan Summary
CONFIDENTIAL
|Name: Ima Client |Therapist: Ima Therapist, M.A. |
|Date of Report: 08/11/20 |Supervisor: Berta J. Summers, Ph.D., HSPP |
Case Closure Reports
These are written when an active therapy case is closed. If termination is discussed with an active client and decided upon either in a therapy session or during a phone contact, a case closure report is due within two weeks of either the termination session or the final contact. Sometimes a specific decision to terminate with a client will not be made but the client will fail to contact the clinic to reschedule missed appointments. If the therapist's efforts to contact the client by telephone are unsuccessful, then the therapist should leave a final message for the client informing them that if they do not contact the clinic by a specified date their case will be closed. This date should be decided upon by the therapist and the supervisor. Therapists should also inform clients in the message (if appropriate) that they can contact the clinic in the future if they are interested in seeking services again or desire referrals to community providers. The case should be closed if the client does not respond by the date specified in the message; a case closure report is then due within two weeks.
The case closure report provides the final DSM-5 diagnostic codes, a measure of functioning (e.g., WHODAS 2.0), and covers the entire course of therapy (or, if a transfer case, the entire course of therapy with you as therapist). The topics are the same as those used in the transfer summary. Statements concerning the reason for termination and whether termination was mutually agreed upon should be included, as should recommendations for future treatment.
If appropriate, clients can be mailed or provided in person (if a planned termination) a “termination packet.” This packet should contain a cover letter approved and signed by your supervisor, as well as a list of emergency numbers, a completed sheet on how to find an effective therapist, and any applicable community referrals.
Case Closure Reports are due in their finalized form two weeks after the final termination session/phone contact or the date specified in the phone message. All Case Closure Reports should have an “information box” as a header to the summary, in the following format.
Click here for an outline of the sections and content of a closure report [at end of this document].
Termination Report
CONFIDENTIAL
|Name: |Ima Client |Number of sessions attended: |19 |
|Date: |08/15/20 |Number of sessions cancelled: |1 |
|Therapist: |Ima Therapist, M.S. |Number of no shows: |4 |
|Supervisor: |Berta J. Summers, Ph.D., HSPP |Total months in therapy: |6 |
|Tx type/s: |CBT |Termination type: |Mutual |
| | | | |
Transfer Reports
These are written when a client is transferred from one clinic therapist to another and are written by the therapist who is transferring the client. The topics specified for the treatment plan summaries are a good guide for what should be included in the transfer summary. Recommended goals and approaches for future therapy should be given. Additionally, the reason for the transfer and the name of the therapist to whom the client is being transferred should be stated. The specific plan for when and how the client will be in contact with the new therapist needs to be described (e.g., when will the client’s next clinical contact with the new therapist be, what will be the plan for managing risk in the interim between your last session and the new therapist’s first session?). You will want to describe a detailed plan of how the baton will be passed to the new therapist. The transfer report should be written based on what occurred from the last treatment plan summary (or intake report if no treatment plan summary is on file yet) to the present.
Transfer Reports are due two weeks after the last therapy session with the client. All Transfer Reports should have an “information box” as a header to the summary, in the following format:
Transfer Report
CONFIDENTIAL
|Name: |Ima Client |Number of Sessions Attended: |47 |
|Date of Birth: |08/21/80 |Number of Sessions Cancelled: |2 |
|Sex: |Female |Number of No Shows: |1 |
|Race: |White |Total Months in Therapy: |13 |
|Education: |Bachelor’s |Treatment Type(s): |CBT, IPT |
|Therapist: |Ima Therapist, M.A. |Date of Report: |08/20/20 |
|Supervisor: |Berta J. Summers, Ph.D., HSPP | | |
Case Reopening
If a former client requests services after a previous termination from the clinic, then a case reopening report can be written. This is almost identical to an intake report except that it clearly indicates that the client has previously received services in the clinic and background information does not need to be described in as much detail; the reader can be directed to see the previous intake report(s) for more detailed information (the date(s) of the previous intake report(s) should be specified). The case reopening report must update the previous intake and note any changes that have occurred since the client was last seen in the clinic. A summary of the DSM-5 diagnoses and a measure of functioning (e.g., WHODAS 2.0) score are required for every case reopening report.
Case reopening reports are due in their finalized form two weeks after the updated intake information is gathered. All case reopening reports should have an “information box” as a header to the report, in the following format:
Case Reopening Report
CONFIDENTIAL
|Name: Ima Client |Occupation: Accountant |
|Date of Birth: 08/03/89 |Marital Status: Single |
|Age: 28 |Date(s) of Interview: 08/04/20 |
|Sex: Female |Date of Report: 08/16/20 |
|Race: African American |Therapist: Ima Therapist, M.A. |
|Education: Master’s |Supervisor: Berta J. Summers, Ph.D., HSPP |
Contact Summaries
A Contact Summary is written when you have only had limited contact with a client (typically over the phone only, or one intake session) or only attempted contacts with a client. This report will be brief and consist of a detailed summary of the contacts and/or attempted contacts you have had with the client, in addition to a brief summary of the presenting problem (i.e., why the client is seeking treatment). Examples of scenarios in which you would write a contact summary are:
• You have been assigned a new client and are unable to reach the client to schedule an initial appointment. You have called three times and left messages, but the client has not returned your calls. In your final message, you informed the client you will close his or her file if you do not hear from him or her by a certain date (agreed upon by you and your supervisor).
• You have talked to a new client on the phone on one or more occasions, but the client has not shown up for an initial session (either due to several cancellations or no-shows). In your final message, you informed the client you will close his or her file if you do not hear from him or her by a certain date (agreed upon by you and your supervisor).
• You successfully get in touch with a new client, schedule an intake appointment, and the client comes to the first intake appointment; however, you are unable to reach the client after this point. In this scenario, if you finished your intake in the first session, you should write an Intake Report. If you do not have enough information for diagnostic impressions after the first intake session, you will write a longer version of a Contact Summary in which you summarize the contact you have had with the client to date and also summarize the information gathered in the intake interview. This Contact Summary must include a suicide risk assessment and actions taken, as well as a statement indicating that not enough information has been gathered to make diagnostic impressions at this time.
Contact Summaries are due in their finalized form two weeks after the final contact (phone, session), the final attempted contact, or the date specified in the final phone message. All Contact Summaries should have an “information box” as a header to the report, in the following format:
Contact Summary
CONFIDENTIAL
|Name: Ima Client |Therapist: Ima Therapist, M.A. |
|Date of Report: 08/11/20 |Supervisor: Berta J. Summers, Ph.D., HSPP |
Intake Report Outline
Intake Report
CONFIDENTIAL
|Name: Ima Client |Occupation: Accountant |
|Date of Birth: 08/03/90 |Marital Status: Single |
|Age: 30 |Dates of Interview: 08/04/20; 08/11/20 |
|Sex: Female |Date of Report: 08/23/20 |
|Race: African American |Therapist: Ima Therapist, M.A. |
|Education: Master’s |Supervisor: Berta J. Summers, Ph.D., HSPP |
At beginning of intake:
Intake process
Fees: Treatment – (Regular session fee will be: $_____)
No-show – equivalent to full session fee
Confidentiality and limits thereof:
Danger to self and others
Risk to protected populations
Legal proceedings (e.g., subpoena)
Supervision structure (practicum students only)
Permission to record
The client agreed to all Clinic policies and procedures, including confidentiality, videotaping and observation, fees, and case assignment procedures. The client was given an opportunity to ask questions about the clinic.
Identifying Summary
The client is a ____ year old , ___[race]___ [male/female], who is presently living in ____________ with ___...and is employed as a ________ [job title] at ___ (or in school at ___), etc.
Presenting Problem(s)
Provide a thorough narrative summary of the current problems for which the client is seeking treatment. Insert current symptoms and description of how they manifest themselves and how severe they are. Antecedents and consequences as determined by your verbal retrospective functional analysis are relevant, as would be client self-monitoring data you might have asked them to keep during the first couple of weeks. Events/situations that exacerbate and ameliorate symptoms are informative for treatment planning. Include quotes of client's description of the problems whenever appropriate and particularly descriptive to do so. Also, you can include comments about the client’s stated goals for treatment, ideally, operationally defined. Below are some questions to consider (include remarkable information only):
A. Nature of the problem
B. When was the condition first noticed? Sudden vs. gradual onset? Life circumstances at onset?
C. Under what conditions is it currently most problematic?
D. Under what conditions is it currently least problematic?
E. Dimensions of the problem (e.g., frequency, duration, pervasiveness, magnitude)
F. Corrective measures attempted in the past
G. To what extent and how were corrective measures helpful in attenuating symptoms?
H. Who sees it as a problem (client, significant others, court)?
I. Why are they seeking help now?
J. Effects of the problem on current adjustment:
a. Interpersonal
b. Work or school
c. Community (legal, economic, social)
d. Intrapersonal
i. Physical
ii. Emotional
iii. Intellectual (e.g., judgment, concentration)
iv. Behavioral (e.g., impulsiveness)
v. Self-appraisals (e.g., low self-esteem, helplessness)
K. What would it look like if the problem were no longer an issue for you? How would things be different?
Harm to Self and/or Others
Do you have thoughts about taking your own life? Or someone else’s?
Suicide risk was assessed according to Joiner et al. (1999; Chu et al., 2015) and was determined to be __________ (low, moderate, severe) due to ________________ (risk factors, history of attempts, content of ideation, plans/preparations, level of desire/intent, access to means, etc.).
Suicidal Ideations:
Death Ideations:
Suicidal Intent: Rated current suicidal intent as __/10
Desire: Rated current suicidal desire as __/10
Plans and Preparations:
Past or New Means:
Access to Means:
Does the patient have access to a gun?
ACTIONS TAKEN (not all of these are necessary, depends on the presentation):
1) created safety plan (see data form);
2) informed of 1-800-273-TALK and option of voluntary hospitalization;
3) encouraged means restriction, including _______________;
4) scheduled a mid-week phone check-in for _______ at ______; and
5) emailed/forwarded an update on suicide risk status and actions taken to supervisor(s): _____________________
If homicidal ideation is expressed, assess the following:
Homicidal ideation, intent, plans, preparations, access to means involved in plan (current, recent history, and lifetime history)
History of homicidal behavior and/or violence
Document actions taken to address current risk
Substance Use
Review current and past use (quantity and frequency of use), but add comments that pertain uniquely to your client's use pattern and related problems, negative consequences from substance use, insight into the problem, etc. Completely describe what is going on in terms of symptoms that might or might not be present (loss of control over use, legal problems due to use, family conflicts caused by use, tolerance, withdrawal, etc.)
Do you smoke cigarettes? Frequency?
How often do you use alcohol?
How often do you use other drugs? (what, how much, how often)?
Have you thought about stopping now? Why? Have you tried to stop before? Why?
Have other people expressed concerns to you about your (alcohol, drug use)?
Treatment History
List any previous assessments/treatment, including where and when it was obtained, and for what type(s) of problem(s), including both mental health and substance abuse. Indicate the treatment modality, whether or not the client found it helpful, and why or why not.
Have you ever been formally assessed and/or diagnosed for your (presenting problem)? Have you received treatment for your (presenting problem) in the past? (where, when, in/outpatient): How successful was it? What was particularly helpful? What wasn’t helpful?
Current Medications
List medications, dosages, comments regarding the purpose of the medication and the client's feelings about taking it, including whether or not the client seems to be compliant with medication requirements and their level of effectiveness, from the client’s perspective.
Mental Status and other Behavioral Observations
Mental status summary should include information on appearance, activity level, speech patterns, attitude towards the interview/interviewer, thought processes, emotional expressiveness or lack thereof, cognitive orientation/organization, memory, insight & judgment. Add some of your own material regarding behavioral observations. Try to include supplemental information that will capture unique aspects of your client's clinical presentation.
Appearance (height, weight, manner of dress, grooming)
Appropriateness of affect (flat, blunted, labile)
Mood (depressed, elevated, anxious)
Appropriateness of interpersonal interactions (including eye contact)
Orientation to time/place/person
Insight/judgment (poor, fair, good)
Speech/thought content (logical, coherent, rational, sentence structure/goal orientated)
Observable idiosyncrasies (tics, odd behaviors)
Reported hallucinations and/or delusions
Assessments
If any assessments/questionnaires were administered at intake (BDI, BAI, YBOCS, etc.), insert a summary of those results here, and also include reference to them, as appropriate, in your final paragraph of this report (Clinical Formulation).
Biopsychosocial History
Developmental History
Describe pertinent issues related to development, including pregnancy complications, achievement of developmental milestones at appropriate/delayed times, problems experienced in childhood, childhood medical history, etc. Indicate how the client describes these things and whether or not any problems were evident to others (parents, teachers).
Tell me a little about your childhood. Any developmental problems (i.e., learning disability, physical disability) or major illnesses or injuries as a child
Any other problems (deaths, frequent moves, divorce, etc.):
Medical and Disability History
Describe any medical diagnoses. Are these being monitored/addressed by a medical professional? Any reason to create a line of communication between therapist and medical provider?
Abuse and Other Trauma History
Describe pertinent issues related to abuse or traumatic experiences. What happened, when was it, who was involved, and what was the outcome?
Is there a history of violence or abuse in your family?
Have you experienced violence or abuse (sexual or domestic)?
Have you experienced any other traumatic events in which you feared for your life and/or experienced or witnessed serious injury?
Family History
Describe parents in terms of current ages, living/deceased, marital status, and employment. Discuss family relations in as much detail as pertinent, with emphasis on client's impression of how these things might be affecting him/her now. Include any information on family history of mental illness or substance abuse.
Tell me about your family (past and present, parents, brothers, sisters, etc., mental illness, suicide, substance abuse, violence, etc.):
How would you describe your relationship with your family members?
What aspects of your family or past continue to affect you today?
Who lives in your immediate household? Quality of relationships with them?
Family hx of mental illness, suicide, substance abuse, violence or abuse (sexual or domestic)?
Cultural/Spiritual History
a) Acculturation issues
Describe length of time client is living in the United States. How many generations of client’s
family has been living in United States. What is the ethnicity of significant others in the client’s family? Describe any difficulties/conflicts related to cultural background and adaptation to the American culture. Describe additional acculturation issues: (e.g., frequency of interaction with own and other cultural/ethnic groups.)
b) Cultural and racial identity
What is the client’s self-perceived cultural identity? Does client identify self as belonging to a distinctive cultural or ethnic group? Specify. Does client identify with a distinctive racial group? Explain.
c) Spiritual/Religious history
Describe spiritual beliefs and religious practices, current religion, religion of upbringing. how often/intensely the client practices his/her religion? How frequent does, he, /she pray or attend religious services? Do religious practices or spiritual beliefs have an impact on treatment? In what way? Describe any significant religious/spiritual beliefs, practices, or experiences of the client has had. If the client has consulted a religious leader/healer regarding his, or her presenting problem please explain. Indicate any recommendations given and their impact. Additional religious factors: (e.g., change of religions, religious beliefs affecting treatment, etc.
Educational History
The client completed ___ years of school Indicate educational goals if still in school, and indicate reasons for dropping out if school plans were not accomplished.
How far did you get in school?
If school plans were not accomplished, why not?
Tell me about how school was for you when you were growing up:
Any plans for additional education?
Employment History
List employment history, relationships with coworkers and supervisors, as relevant etc.
Do you work outside the home? Where? To what extent do you enjoy your job?
How would you describe your relationship with coworkers? Supervisors?
Social History
Include social supports, hobbies, or past problems getting along with people, etc.
How would you describe your relationships with peers (e.g., lots of friends, isolated)?
How would you describe your support network? Do you have friends or family that you can rely on in an emergency?
Have your ever been involved with a gang? How do you respond to authority, supervisors, police officers?
What do you enjoy doing? Any hobbies and interests?
What do you do in your free time?
Case Formulation
Provide a narrative summary of the case, here. Include a summary of the pertinent historical and current issues. Attend to “5Ps”: Presenting, Predisposing, Precipitating, Perpetuating (Positives = “Strengths”, captured below). Include attention to Cultural Formulation as appropriate to the case.
Strengths
Try to capture what is unique about your client, and emphasize things that might be relevant to treatment, whenever possible, e.g., good expressive language, intelligent, cognitively impaired, good social skills, etc.
DSM-5 Diagnosis
You must put down something, even if it is a Rule Out (R/O) diagnosis, or you just might have to list "deferred" if there is nothing you can say for sure at this point. It is OK to list several diagnoses, if they apply. You must include the diagnostic code as well as the formal diagnostic label. For any assigned diagnosis, it is critical to outline the specific symptoms and duration to justify this from a DSM perspective.
Primary:_____.____ ____________________________________________
Additional:_____.____ __________________________________________
Additional:_____.____ __________________________________________
Client Goals
How would you know that treatment was going well? What would change about your life? What would you hope to achieve or learn? How would you know that you were ready to end treatment successfully?
Initial Treatment Plan and Recommendations
Provide some recommendations as to how this case should be handled, in terms of initial goals, type of treatment (CBT, behavioral, insight oriented, etc.), frequency of sessions, any referrals that should be given to the client, potential involvement of any other important people (family, other treatment providers) in the case, etc. Indicate if any psych testing should be conducted. If suicidality or homicidality are issues in this case, you must mention them here, and include a plan for monitoring and amelioration. Also cover any other high-risk behaviors. Basically, here you are summarizing the case and providing a preliminary treatment plan that will guide the therapist until a formal treatment plan can be developed.
__________________________ ____________________________
Ima Therapist, M.A. Berta J. Summers, Ph.D., HSPP
Psychological Trainee Supervisor
Termination Report Outline
Termination Report
CONFIDENTIAL
|Name: |Ima Client |Number of sessions attended: |19 |
|Date: |08/15/20 |Number of sessions cancelled: |1 |
|Therapist: |Ima Therapist, M.S. |Number of no shows: |4 |
|Supervisor: |Berta J. Summers, Ph.D., HSPP |Total months in therapy: |6 |
|Tx type/s: |CBT |Termination type: |Mutual |
The TERMINATION SUMMARY is the one report most likely to be read by someone in the future (e.g., when records are requested). Think of the person who may be working with your client in the future as your audience and review the entire course of your work with the client.
Reason for referral:
As per described in the Intake. When/why did the client present for services? Describe briefly the original complaint in client’s own words and its change throughout the course of treatment to the present.
Client history:
Knowing now all that you have learned about the client, summarize the most relevant factors, facts and events in the client’s developmental, cultural, family, medical, social, educational and work history. If you are going to describe changes, you must summarize the original situation described during intake to help the reader that may not have the intake to review.
Presenting problems and stressors
Current environment
Alcohol and substance abuse
Developmental and social history
Gestation, infancy, childhood, and adolescence
Psychosexual history
Educational/Vocational history
Social history
Criminal/Legal history
Family history
Family composition and significant history
Family psychiatric and medical history
Medical history
Multicultural evaluation
Language
Migration history, if applicable:
Cultural and racial identity
Spiritual/Religious history
Acculturation
Assessment of risk: In this section, discuss clients risk level over the course of treatment and ways that this has been successfully managed. Also be clear about the client’s CURRENT risk, as of termination.
Suicide risk was assessed according to Joiner et al. (1999; Chu et al., 2015) and was determined to be __________ (low, moderate, severe) due to ________________ (risk factors, history of attempts, content of ideation, plans/preparations, level of desire/intent, access to means, etc.).
Summary of clinical impression and course of treatment:
Briefly summarize objective aspects of the service provision over the entire course of the treatment covering matters such as frequency of sessions, client’s response to treatment structure (e.g. fees, appointments), and summarizing material from progress notes and the treatment plan. Briefly review the issues and problems that were of main concern at each phase of the treatment process. Include any relevant cultural information here, as well (e.g.,
If client provided a cultural explanation of his/her presenting problem, indicate if there were any changes in that understanding).
Provide final Clinical formulation and impressions. Summarize your understanding of the nature, etiological, and maintenance factors of the client’s problem (from a cognitive-behavioral perspective). State your assessment of the client’s motivation and expectations for treatment; describe the client’s strengths and areas that need continued support. Integrate your own insights and relevant data from the preceding sections in this section.
Describe what treatment modality you used to address the patient’s presenting problem. Describe progress and changes in all of the above. Include all major diagnostic and treatment considerations that were part of the work with the client. Include any changes in skills, coping styles, cognitive appraisals, behavioral avoidance, and general maintaining factors since the beginning of treatment. Provide supportive reasoning behind the diagnosis.
Conclude with a discussion of the termination. Why is the case being terminated at this time? What are the client’s feelings about termination?
Mental Status Examination (at the time of termination):
Appearance (height, weight, manner of dress, grooming)
Appropriateness of affect (flat, blunted, labile)
Mood (depressed, elevated, anxious)
Appropriateness of interpersonal interactions (including eye contact)
Orientation to time/place/person
Insight/judgment (poor, fair, good)
Speech/thought content (logical, coherent, rational, sentence structure/goal orientated)
Observable idiosyncrasies (tics, odd behaviors)
Reported hallucinations and/or delusions
Diagnoses:
Whether or not the diagnosis has changed, enter a full, DSM 5 diagnoses here. Justification for all diagnoses (symptoms, duration) should be included.
Original DSM-5 Diagnoses:
List all relevant diagnoses, with codes and labels. Indicate “Rule Out” “Deferred” or “None” when necessary.
Primary:_____.____ ____________________________________________
Additional:_____.____ __________________________________________
Additional:_____.____ __________________________________________
Final DSM-5 Diagnoses:
If the diagnosis has not changed, simply state this by indicating “same as above.” Otherwise, give new diagnostic impressions here, using the same format as above.
Primary:_____.____ ____________________________________________
Additional:_____.____ __________________________________________
Additional:_____.____ __________________________________________
Final Recommendations and Disposition:
Your last words as you look ahead! What is the client’s prognosis? What work remains to be done? Include clinical and multicultural aspects. What is left to say about the client? What was discussed with the client in terms of future recommendations and disposition? How did client feels about disposition plan? What might be helpful to a future professional who someday may be reading your report?
Please indicate:
Handouts/information provided:
Referrals given:
Emergency numbers/reminder of safety plan:
__________________________ ____________________________
Ima Therapist, M.A. Berta J. Summers, Ph.D., HSPP
Psychological Trainee Supervisor
Monitoring of Files
Once every semester the director monitors whether reports have been filed by their due dates and will send an individual email to therapists and their supervisor/advisor/DCT about any outstanding reports or data forms. If by the end of the semester, late reports have not been filed, therapists may receive an unsatisfactory for the clinic practicum course.
PROGRESS NOTES
Progress notes provide records of all interactions concerning the client as well as an up-to-date summary of therapy sessions. Every contact with the client (by phone, in-person, e-mail, or by mail), or concerning the client, must be recorded in the progress notes, no matter how trivial the contact may seem. Essentially, all events relevant to the client should be recorded in the progress notes. A progress note should be written immediately after an interaction or event. If this is not possible, the note should be written within twenty-four hours.
(Your Name, M.S.)
Supervised by Berta J. Summers, Ph.D.
Progress Note Example (Template in Titanium as “GPAC Session Note”)
Client name: Mr. D
Date of service: July 12th, 2020 (11:00am)
Session type: Psychotherapy
Session number: 5
Type of therapy: Outpatient CBT
Total time of session (in minutes): 50 mins
Assigned diagnosis: Major Depressive Disorder (F33.0)
Symptom Description and Subjective Report:
Mr. D. stated that he has “generally been doing well” since the previous session. He reported that his depressive symptoms have improved, but he still feels “down” at times. Mr. D. reported he is sleeping “better” and getting “decent sleep.” He feels therapy is helping him to address his “negative thinking”. Client reported no change in anxiety and continues to avoid most social situations.
Relevant Content & Objective Information:
BDI = 19
BAI = 12
In service of client’s long-term goal of improving mood and reducing anxiety, the current session focused on addressing negative automatic thoughts in social situations and discussing an interpersonal stressor at work. Collaboratively set agenda and obtained update on significant life stressors over the past week. Reviewed homework of observing automatic thoughts in anxiety-provoking situations. Through this discussion, client was able to identify several automatic thoughts (e.g., “I should have more to say”). Introduced cognitive restructuring, provided rationale, and practiced completing though record. For the remainder of the session, used reflective listening as client discussed recent interpersonal stressor at work.
Interventions Used: (Check all that apply)
Psychoeducation
Treatment Planning / Review of progress
Motivational interviewing
Cognitive restructuring
Behavioral activation
Exposure and response prevention
Stimulus control / Habit reversal
Structured Problem Solving
Supportive Reflection
Other: _________
General Assessment: The long-term goal of improving mood and reducing anxiety remains appropriate and client is making progress towards this goal, as evidenced by his subjective improvement in mood and decrease in BDI score.
Risk Assessment and Safety Plan: Suicide risk was assessed according to Joiner et al. (1999) and Chu et al. (2015) and was determined to be moderate based on history of attempts and current level of psychopathology. When asked, Mr. D denied having any thoughts of death or suicide, and he denied any plans or preparations for a suicide attempt. He reported his level of intent for suicide was 0 out of 10. Actions taken: (1) in the case that he experiences thoughts of suicide, reminded Mr. D of his safety plan, (2) reminded of 1-800-273-TALK (8255), (3) reminded of voluntary hospitalization and 911, (4) will continue to monitor risk.
Treatment Plan and Homework: Continue weekly individual CBT. Next session will continue to focus on cognitive restructuring. Client agreed to complete thought record once per day.
Mental Status Exam:
|Appearance |Clean |Well-groomed |Inappropriate |Unkempt |
| |Disheveled |Other | | |
|Attitude |Cooperative |Belligerent |Anxious |Evasive |
| |Guarded |Hostile |Impulsive |Passive |
| |Suspicious |Withdrawn |Other | |
|Posture |Relaxed |Rigid |Slumped |Other |
|Eye Contact |Direct |Downcast |Staring |Little |
| |Other | | | |
|Orientation |Person |Place |Time | |
|Expression |Appropriate |Blank |Crying |Frowning |
| |Gesticulation |Laughing |Menacing |Screaming |
| |Smiling |Other | | |
|Movement |Calm |Fidgeting |Slow |Agitated |
| |Hyperactive |Ritualistic |Disorganized |Impulsive |
| |Tics |Grimacing |Tremors |Pacing |
| |Other | | | |
|Speech |Coherent |Clear |Delayed |Excessive |
| |Incoherent |Loud |Minimal |Pressured |
| |Slurred |Soft |Other | |
|Mood |Euthymic |Angry |Anxious |Euphoric |
| |Fearful |Sad |Irritable |Other |
|Affect |Congruent |Full |Anxious |Blunted |
| |Constricted |Fearful |Labile |Irritable |
| |Sad |Apathetic |Expansive |Flat |
| |Other | | | |
|Neuroveg Sxs |Sleep |Interest |Guilty |Energy |
| |Concentration |Appetite |Psychomotor |Libido |
|Thought Process |Direct |Normal rate |Blocking |Loose associations |
| |Flight of ideas |Illogical |Impoverished |Circumstantial |
| |Perseveration |Tangential |Withdrawal |Other |
|Thought Content |Coherent |Obsessions |Compulsions |Guilt |
| |Ideas of reference |Other | | |
Below is information about writing progress notes in Titanium. Many of the notes in Titanium have templates already included in them that simply require the therapist to fill in the relevant information (e.g., “GPAC Session Note”). Unless otherwise instructed, do not delete parts of the template for individual therapy/assessment notes. All notes need mental status, session content, symptom assessment, diagnoses, medical information, suicide risk, and plans for follow up for every session. You are welcome to write a master note and copy and paste things (like the suicide section for low risk clients) but be very careful not to copy and paste things that need to be changed session to session.
General Information
• All progress notes must have dates & times. The date and time entered in Titanium should be the date/time of CONTACT with a client, not of entry into the file.
• If you refer to a date in the content of the note, it should include the year and date (not just the day of the week or a descriptor like “yesterday” or “tomorrow”)
• Each session with a client should have a main progress note plus separate progress notes for measures given and/or homework documents!
o Homework should be uploaded at your discretion. If you do upload homework, please describe homework completion in the note. These notes should be linked to the date & time of the appointment.
• Please notice the red underlines that indicate you have words misspelled so that supervisors do not have to unlock and resign notes for small but glaring spelling errors!
• Do not delete parts of the templates (e.g., GPAC Session Note).
• Forward all notes to your supervisor
• Suicide risk level should be documented at every session, even for non-suicidal low risk children and adults. If you do not do a risk assessment that day, use the text below and delete the remainder of the suicide information from the template. This is only to be used for consistently low risk clients. Your supervisor will help guide you because questions about risk and your assessment will come up in supervision. If you do NOT complete a full risk assessment, fill out the provided template
o “Suicide risk was assessed according to Joiner et al. (1999) on DATE and was determined to be ____ due to ____. CLIENT's risk status remains unchanged from the last assessment, as evidenced by current symptoms and behaviors described above. (Your note should adequately describe other symptoms that suggest risk level--mood, sleep, appetite, activities, etc...) Suicide risk will continue to be regularly monitored.”
Communication w/Clients
• PDFs of email communication should be attached to a progress note. The limits of confidentiality over email should be discussed with your client before any email communication is had.
• The content of faxes/letters should also be attached to a progress note.
• You are allowed to summarize text message communication (instead of writing the content out verbatim or taking screen shots) in the progress notes.
GENERAL POLICIES & PROCEDURES
Policy on Exchange of Client Information within the Clinic
By virtue of becoming a client at the clinic, the person agrees to an exchange of information between clinic staff members concerning him/herself (e.g., team members discuss cases, cases are presented at meetings with clinic staff, and graduate assistants may handle client materials). However, the clinic operates on a "need to know" basis and information is exchanged only when it is in the best interest of the client or is necessary for the operation of the clinic. Therapists and other staff members need to be sensitive to the difference between gossip and professional exchange of information, which should only take place behind closed doors (i.e., not in public where the conversation can be overheard, even if a name or other identifying information is not used).
If two family members are seeing different therapists in the clinic, a therapist should not discuss their client with the other therapist unless permission is obtained from the client. To help maintain client confidentiality, therapists should use only client initials and omit or alter identifying information when discussing cases. This includes discussions, case conferences, and case presentations during staff meetings. When addressing clients directly while others are nearby, therapists and staff should avoid using clients' last names.
Your supervisor may prefer to correspond with you via email. Please be particularly careful when describing a client issue over email (e.g., by using initials) and if attaching a document for review, be sure to password protect your documents with the clinic password. The clinic password changes yearly and when prompted at the start of the new year therapists should change the password accordingly on all documents they send to their supervisor.
Release Forms Used When Communicating with Others outside the Clinic
The form described below must be used when releasing client information to and/or requesting information from others outside the clinic. Blank forms should never be signed by the client. The forms are available in the main office.
Releasing Information to Others
A signed and current Release of Information Form is needed before any verbal or written information about a client can be released from the clinic to another party. All forms must be dated and signed by the client (or legal guardian in the case of a minor) and must specify the agency, person, organization to whom the information is to be released, the purpose of the release, and the specific information that is to be released. Additionally, this should be completed when releasing records to a client.
Policies and Procedures for Releasing Client Information Outside the Clinic
Therapists, with authorization from their supervisors, are responsible for preparing and sending to others any written materials concerning their current clients. An exception to this is records requested through a subpoena or court order; all subpoenas and court orders should be given immediately to the director. For former and current clients, the following steps must be followed and issues considered before releasing any information from the clinic:
1. A completed, signed, and current Release of Information form must be in the client's file. Possible substitutes for these are release forms sent to the clinic from another agency or person requesting that we release information to them about the client; these forms must be on the person's or agency's letterhead and appropriately completed, signed by the client, and dated. For former clients, an acceptable alternative is a dated and signed letter from the client to the clinic requesting that information be released to a specified person or agency. In both cases, the signature should be compared to the client's signature on record in the file in an attempt to verify the authenticity of the request.
All originals of the signed clinic release forms and copies of the cover letter sent with the materials are to be uploaded to Titanium.
Before a client signs a release form, the therapist should make sure the client understands any potential implications involved in releasing the information.
2. A valid, current release form is one that has been signed (a) within sixty days prior to the release of information or (b) sometime before services are terminated, whichever is later. In the latter case, it is advisable to have a client sign another form if the previous one was signed more than one year ago and information must be released again.
2. A client has the right to refuse to sign a release form and may revoke a previously signed form at any time; however, the revocation would have no effect on action taken previously.
3. There are certain exceptions to the rule that written consent must be obtained prior to releasing information:
• By law, suspected abuse of children, the elderly, and the disabled must be reported to the appropriate authorities.
• If a person is considered dangerous to him/herself or others, then appropriate action must be taken (e.g., involuntary hospitalization; warning others about threats of physical harm made against them by the client).
• Information must be released if a judge issues a court order directing the clinic to release the information (court orders cover all materials pertaining to a client, including audio- and videotapes and therapists' notes not kept in the client's file in the main office). If you ever receive a court order or a subpoena, you must immediately notify the director and your supervisor. Do not take any action before you have consulted them; they will contact the university lawyers.
4. Information in a client's file that originated elsewhere and was subsequently released to the clinic (e.g., an assessment report written by a school psychologist) cannot be released by the clinic to a third party unless the client specifically consents in writing to the release of this information. Similarly, information released from the clinic cannot be re-disclosed by the receiver (except if the receiver is the client) unless the client provides specific written consent for the subsequent disclosure. To help ensure that re-disclosure of clinic materials does not occur without authorization from the client, every page of each report and summary released from the clinic should contain the following statement: "Confidential: not to be released without further written consent from the client or guardian."
5. The best rule to follow in deciding how much to disclose to third parties about confidential information can be designated the "rule of austerity": the minimal necessary information to answer the question posed by the third party is the preferred amount. It should never be necessary to release a client's entire file unless a court order is issued by a judge.
6. It is clinic policy to release information to professionals and not directly to the client when possible. Exceptions to this policy may be made at the discretion of the therapist and supervisor (or the director in the case of former clients). For example, learning disability and gifted assessment reports are typically released to the client. If a client requests access to all or part of their record, the therapist should get clarification on the reasons underlying the request. If it is deemed appropriate by the supervisor and therapist to release information, it may be best to give the client a written report summarizing the contents of the file. Progress notes are only released when the clinic is legally obligated to do so – this should be done in consultation with the director. Only under rare circumstances should a client be allowed to have access to information from the file if there is reason to believe that it may cause the client undue emotional tension or anxiety, or to result in the client's refusal to engage in needed treatment. Written material should be given to the client during a scheduled meeting at the clinic; the therapist and client should discuss the released information after the client reads it.
Whenever a client receives written information from the file, they should sign a Release of Information form specifying that materials were released to "self." This protects the clinic in the event that the client shares the information with others for whom the clinic does not have authority to release information. This release is not needed for assessment reports provided as part of the feedback session. Entries should be made in the progress notes whenever clients are given access to information from their files.
When writing reports, summaries, and progress notes, it is useful to assume that the client will someday read them.
8. Similar to #7 above, consideration should be given to the information that is being released to third parties and the potential consequences of releasing such material. Therapists should read all materials carefully before releasing them, keeping in mind the intended reader. If necessary, a summary omitting potentially sensitive information can be released. A good rule to follow is to not include sensitive information in the file in the first place. However, supervisors differ in what they consider to be sensitive information and whether it should be included in the file, so questions about whether to include specific content should be addressed to the supervisor. Raw data, such as testing protocols are not released unless they are being sent to a licensed psychologist who is qualified to interpret them. Even in such cases, sending a summary report is preferred.
9. Information about a client cannot be released to relatives (except in the case of a minor child's parents), including spouses, parents of adult children, and siblings, without the written consent of the client.
When a child or adolescent is seen for therapy, the therapist needs to determine at the beginning of treatment how much information disclosed by the client will be shared with the parents. Guidelines for this decision should be established with the supervisor and any limits on disclosure should be discussed with the parents and child or adolescent at the beginning of therapy.
10. Information about a client cannot be given to anyone (including relatives, except in the case of parents of a minor) over the phone unless we have written consent from the client authorizing us to release information to that individual. Therapists should keep in mind that it is difficult to know the true identity of someone on the phone and should be certain about the person's identity before disclosing information.
If someone calls the clinic asking if Mr. X is a client, they must be told that we cannot provide such information in light of laws concerning the confidentiality of clients. If they mention there being a release, you may proceed by asking for the clients name and say that you will check to see if the client is in fact a client and that there is a release. Note that you will only return their call if there is a release, otherwise you’ll reiterate your inability to say whether or not there is a client here by that name.
11. Care must be taken when calling a client. A therapist should not identify their affiliation with the Psychology Clinic when speaking to anyone other than the client (e.g., if a message needs to be left), unless the client has given permission for this. Judgment should be used if it is necessary to leave the clinic phone number so a client can return the call; the person being given the message can call the number and find out the therapist's affiliation. In most circumstances this should not be a problem, but therapists should be aware of situations that may make this a sensitive issue. An alternative is to ask when the client is expected to return and s/he can be called at that time.
When someone other than the client answers the phone, the therapist should identify him/herself by name, if asked. Vague responses like, "a friend" or "never mind, I'll call later" may create the perception of a cloak-and-dagger situation at the other end of the line. Again, always check the client contact preferences concerning this issue.
12. No materials should be released by a therapist without authorization from the supervisor.
13. Records on released information must be carefully maintained. The name and address of the agency or person (including the client) receiving written materials, the materials they received, and the date the records were released must be recorded in the progress notes (a scanned copy of the materials sent should be attached to the note). Information that is released verbally to others should also be noted in the progress notes.
Payment Deadlines
Therapy
Payment for intakes and therapy are due the day of the session. Charges for phone calls, school and home visits, and missed appointments are due the day of the next session held at the clinic.
Assessments
The total fee for assessments is due on the final day of testing. Clients must pay the fee prior to receiving the report. Clients must be informed of this before scheduling the assessment.
Therapists' Responsibility
Therapists should be aware of their clients' balances on an ongoing basis. If clients do not pay on a regular basis, according to the timelines specified above, therapists should raise this issue in supervision and discuss it with the clients. A guideline to use in determining when to raise the issue is two sessions without payment.
If someone other than the client is responsible for payment, the therapist should have the client sign an Exchange of Information form that stipulates permission to discuss the client's financial obligations to the clinic. This is to protect the clinic in case we have to contact or send a bill to the individual responsible for payment. A release of information must also be signed before information is released to an insurance company (note, however, that we do not bill insurance!).
Insurance
The Clinic does not bill insurance companies. Our clinicians are not licensed psychologists and are not contracted with insurance companies. Because of this, the policy is that all fees are due when services are rendered. Some clients may request documentation of the services they received so they can submit a bill to their insurance company and we will provide clients a statement with the necessary information for them; e.g., session dates, procedure codes and diagnosis codes. The clinic does not accept payments made by Medicare or Medicaid.
If a client wants a report released, the therapist must have the client sign a Release of Information form and should describe to the client the basic content of the reports; in most situations it will be best for the therapist to write a report summarizing the information requested and to have the client read the summary before signing the release form. Reports and summaries should not be released without authorization from the supervisor.
EMERGENCIES
Although the clinic is not designed as an emergency facility, therapists can expect to be called upon to handle emergencies. Most often, emergencies will involve a therapist's on-going case. However, an individual who is in distress and is not a client will occasionally come to the clinic for help. In these cases, it is our ethical responsibility to assess the individual's level of distress and not let her/him leave the clinic until we are certain the risk of suicide is decreased to a safe level or until we have made arrangements for the person to be seen immediately at another facility. Another situation that may arise is the case of a client in distress who calls to speak to their therapist. If the therapist is not in the clinic and cannot be reached within a reasonable period of time, a therapist who is available in the clinic may be asked to speak to the client.
The Suicide Assessment Decision Tree developed by Dr. Joiner is the clinic’s primary method for determining individuals’ level of risk for suicidality. See Suicide risk assessment and emergency procedures.
A list of licensed clinical faculty to call in the event of emergencies can be found at the beginning of this manual. If a therapist's supervisor cannot be reached during a crisis situation, the therapist should leave a message for the supervisor and then try to contact another supervisor. It is recommended that therapists keep in a secure place the list of emergency phone numbers, the list of phone numbers of clinical faculty, and the addresses and phone numbers of clients. (The list of client’s contact information should not be identified as such, but simply kept as any other phone numbers.) This information will help therapists handle emergency phone calls received from clients.
All emergency contacts need to be recorded in clients' progress notes. Non-client emergency contacts should be summarized in a progress note and given to the Director. These notes can be retrieved if someone becomes a client at a future time.
If a supervisor is unaware of a client and/or non-client emergency contact that a therapist has had, they should be informed about it as quickly as possible.
GENERAL INFORMATION
Hours of Operation
The clinic is currently largely remote. However, during non-pandemic times, the clinic will open at 8:00 a.m. and close at 8:00 p.m. Monday through Friday. Your last client should be scheduled to finish no later than 7:50 p.m. A therapist should not remain in the clinic alone with a client without permission. Also, therapists should not walk any client to their car.
The clinic is closed only for national or state holidays (e.g., Independence Day, Memorial Day, Thanksgiving) when all university personnel have the day off. In addition, the clinic usually closes for one to two weeks during winter break and one week during spring break. Otherwise, the clinic remains open and services are provided to clients.
Vacation Policy and Practicum Periods
Because continuity of care is important for clients, the clinic does not follow the university calendar. Services are provided during university vacation periods, including the weeks between semesters (except as noted in the previous section). Therapists should never cancel sessions with clients because of exams or other academic assignments. Therapists should consult with their supervisors and/or the director about taking vacation. Therapists are expected to attend all weekly practicum requirements (attending supervision and meeting their clients). Absences will be excused if therapists are out-of-town on professional business (e.g., attending a conference) or are sick. Therapists should inform the director ahead of time if they are unable to attend a meeting. Supervisors should be informed ahead of time if a supervision meeting will be missed. Therapists who cancel meetings with clients should inform their supervisors of these absences. Missed obligations at the clinic should be infrequent and occur only because of personal or family illness or professional travel.
Website
The clinic has a website, on which potential clients can find information about the clinic.
Professional Behavior
When offering a service to the public, a variety of expectations develop on the part of clients, colleagues, outside agencies, and professionals. Among these are:
• Appointments must be met exactly on time.
• Dress must be appropriate at all times and therapists are expected to present an appearance of professionalism when seeing clients. It should be remembered that even though a therapist may have no clinic appointments scheduled on a particular day, s/he may have cause to see a client unexpectedly (e.g., a walk-in emergency). It would be wise for a therapist to consider whether the chosen clothing might be an embarrassment if unanticipated client contact should occur.
• Deportment throughout the clinic must be professional.
• Therapists serve as representatives of the clinic during professional contacts with others from outside the clinic. Interactions should be professional, and conversations and actions preplanned whenever possible (with consultation from supervisors when necessary). These contacts will influence others' views of the clinic, as well as the reception given to others who subsequently contact the same source.
• Clear, complete, up-to-date, and accurate records must be kept on every case.
• When terminated, cases must be closed formally and immediately.
• Therapists should spend time planning before each session, including reading the literature and setting goals for the session.
The director should be informed of any unusual cases, e.g., suicide risks, homicide threats, potential child custody or other legal cases, and clients with serious medical conditions. Clearly, the supervisor must be informed of these issues and should be contacted immediately in the case of suicidal and homicidal threats.
• Upon termination of a therapist's practicum at the clinic, s/he is responsible for each client until the client formally terminates treatment or has been transferred to a new therapist and has actually begun services with that therapist. In assessment cases or consultations, the case is formally terminated after the family and/or authorized agency is given feedback and an opportunity to discuss the therapist's findings and recommendations. Decisions about who to transfer clients to should be done in consultation with the supervisor and director.
• Therapists may, if they choose, give their cell phone numbers to clients. Some therapists might consider creating a google voice number that they share with clients. It is helpful to articulate clear boundaries around the circumstances when it is appropriate to call.
• When leaving on vacation (or just going away for the weekend) or for other reasons, it is the therapists' responsibility to follow these procedures:
o Fill out the client coverage data form (using the client coverage note type) in Titanium for any moderate risk (or higher) clients that you have. Or if for some reason you have a lower risk client who will need a check-in, be sure to fill this out.
▪ In the progress note indicate when you will be out town, how coverage will be provided, and that your client is aware of this. Clients in this situation should also be notified that you will be out of town and informed about how to contact you (or the person covering you). They should also be reminded of other emergency numbers (e.g., 1-800-273-TALK).
▪ If you will not be available by cell phone, be sure to have someone cover your higher risk clients (consult with supervisor about which clients need coverage).
• Therapists must thoroughly know the Ethical Principles of Psychologists and Code of Conduct, published by the American Psychological Association (). Section 4: Privacy and Confidentiality is particularly important for therapists providing services in the clinic.
Grievance Policy
Occasionally, therapists may have concerns regarding other members of the clinic; thus, a protocol has been put in place to resolve grievances.
• Concerns regarding the graduate assistants, other student therapists, or supervisors should be brought to the Director.
• Concerns regarding the Director should be brought to the attention of the Director of Clinical Training or the Department Chair.
Practicum Requirements
Registration
Therapists must register for practicum during each semester at the clinic: either PSY 594 (Beginner), PSY 694 (Intermediate) or PSY 794 (Advanced). The department will purchase liability insurance for all clinic therapists; the policy is considered valid only if the student is registered for practicum credit. Professional liability coverage includes up to $2,000,000 per occurrence and an aggregate of $4,000,000.
Weekly Therapist Activities
Therapists are expected to engage in specified activities during each week of the practicum. The activities and minimum number of hours required for each are given in detail in a later section. By the end of the two-year practicum, therapists are expected to have a total of 550 hours across all activities listed on the weekly log.
Termination of Practicum at the Clinic
At the end of the practicum, therapists must return outstanding borrowed materials (e.g., test kits and/or books) to the director. All reports, summaries, and notes must be up-to-date and uploaded to Titanium. Appropriate procedures should be followed to close the files of terminating clients. As specified in the previous section on professional behavior, therapists are responsible for clients until terminations and transfers are officially completed.
Practicum Grades
Grades are given on an S/U basis by the supervisor and director and are determined by the following:
• supervisor's written evaluation
• professional behavior demonstrated in the clinic, including the therapist's level of responsibility in regard to their clients and the degree to which the therapist follows through on clinic procedures and policies (including timeliness of reports, summaries, and notes, and legal and ethical matters such as confidentiality)
• attendance at meetings, supervisions, and didactic presentations (attendance is required for all therapists).
Weekly Therapist Activities
This information is related to the previous section but will be discussed separately for the sake of clarity.
Weekly Logs
Therapists are encouraged to document their weekly clinic activities listed below this section, which are expected to sum to 550 hours over the course of the practicum. Therapists may choose to use an excel worksheet or to use an online program such as Time2Track. APA requirements influenced the design of the worksheet. Many internship sites typically require at least 500 hours of face-to-face contact and at least 1000 total hours.
Therapists should track the number of clients they see in different settings and demographic information on those clients, as well as a running tally of the different types of tests they administer, including self-report measures.
If a therapist spends time in clinic related activities such as report writing while waiting for a client who does not show, then the therapist can choose to get credit for a charged no show appointment or for preparation and documentation activities, but not both.
Following is a list of activities that therapists are expected to engage in on a weekly basis. The numbers in parentheses show, on average, the suggested minimum number of hours for each activity.
Direct contact with clients or significant others:
Face-to-face (4.0)
Phone (0.5)
Support Activities:
Report and note writing (3.0)
Library search, review, and planning (2.0)
Supervision:
Regularly scheduled meetings (3.0)
Additional meetings (face-to-face or phone) (0.25)
Total: (12.75)
Direct Contact with Clients
If clients are transferred to new therapists, the departing therapist should try to have at least one co-therapy session with the new therapist and the client. This activity can be credited as a face-to-face contact for the new therapist. During weeks in which there are fewer than three face-to-face contact hours, therapists may increase their observation hours to make up the difference (i.e., ideally, the sum of face-to-face contacts and observation should total at least four hours). Therapists may need to maintain a slightly larger caseload than the required four face-to-face contact hours per week to allow for no shows and cancellations. The time spent on the phone with a client, or with others regarding the client, can be counted toward phone contact time even if a fee is not assessed. Emergency contacts should be included in this section whether or not the client is charged a fee.
A full caseload is typically four clients, including therapy and assessment. Email the director when you are in need of a new case. There should not be any “cherry picking” of cases or holding a spot open in your caseload for a particular type of client (e.g., child versus adult, diagnosis). As soon as a case is known to terminate, you may be assigned a new case. As a result, you may have five cases depending on how quickly you write your termination summary. If you would like additional clients above the full caseload, you must receive your Advisor’s approval first, followed by your supervisor’s/Dr. Summers’ approval.
Observation
New therapists may request/arrange to observe sessions of an advanced therapist. After each observation, the observer can participate in a 15-30 minute discussion of the case with the therapist. Some therapists observe one client on a continuing basis while others observe a different client each week; probably some combination of the two over the course of several months would be most useful.
Supervision
Therapists should come to supervisory sessions prepared to discuss assessment and treatment sessions they have had during the previous week. Preparation should include the following activities on the part of the therapist prior to supervision: reviewing the session (perhaps reviewing taped sessions), scoring and interpreting tests, doing relevant reading, formulating hypotheses, and speculating about directions and treatment methods. Supervision will be most beneficial if it's viewed as an interaction between all members of the team.
Record-Keeping
It is strongly recommended that therapists keep their own records documenting their clinical activities in practicum at the clinic, as well as in community agencies. This should be beneficial when internship applications are filled out. You can use Time2Track for this, as UNCW has an account. Internships generally ask for more detailed information than is provided in the weekly activity logs, including information about the types of clients seen (ages, gender, target problems), the number and types of tests administered, and the treatment approaches used. You should go to the APPIC internship website and view their application, so that you know what kind of records to keep on clients. If you frequently update these practica logs, it will save a lot of time when you are applying for internship. Any records you keep should not include information that could be used to identify the client.
GENERAL TITANIUM GUIDE
Scheduling
• Suicide risk phone check-ins can be scheduled as appointments in Titanium if you would like; however, it is not required
o If you do schedule it as an appointment, it needs to be marked as attended (or cancelled, rescheduled, etc.), just like you would a therapy appointment
• To create an appointment, go to your Titanium calendar, right click, and then select “add individual appointment.” Then search for your client.
• For both financial and hours tracking purposes, make sure the length of the appointment is correct in Titanium
• For cancellations or reschedules, do not delete or drag/drop the appointment in Titanium. You should add an additional appointment to the schedule and in the original appointment, make a note in the comments section about the cancellation/reschedule (no progress note needed)
o To properly cancel/reschedule an appointment in Titanium:
▪ Right click on the appointment
▪ Scroll down to attendance
▪ Click your choice of change of appointment and when the window pops up, chose “All that need attendance, X schedules and X clients”
NEW CASE ASSIGNMENT.
Cases will be assigned by Clinic Director (Dr. Summers). You will receive an email with the patient’s ID#, which can be used to identify the patient in the excel sheet found in the GPAC folder on arcshare. *Look at the “Expressed Interest” tab on the spreadsheet.[pic]
1. WITHIN 48 HOURS OF CASE ASSIGNMENT. Reach out via the GPAC email to introduce yourself and schedule an intake session (during your intake session, you can provide the patient with your personal email address and your google voice number). If possible, plan to schedule the first session for 60-90 minutes to offer additional time to walk through consent forms and gather initial information to determine appropriateness for GPAC services.
---Intro email---:
Dear [patient],
My name is ____. I am a doctoral student clinician at UNCW’s General Psychotherapy and Assessment Clinic (GPAC). I am reaching out because I have been assigned your case and would like to schedule an intake appointment with you to better understand your treatment goals and determine whether we can meet your needs in our clinic!
Due to the COVID-19 pandemic, we can offer online video-based therapy through doxy.me (a secure video chat program for telehealth). This therapy is intended to provide potential clients with increased support—currently free of cost—while our office is closed during this time of increased stress.
We would like to be clear that UNCW GPAC is not able to offer any emergency services. If you feel that you are experiencing a mental health crisis, we encourage you to contact the Mobile Crisis Team 24/7 at 1-866-437-1827, reach out to your nearest emergency medical provider, or call 911.
Below I have listed some possible times when I would be available for an intake appointment. Please take a look and let me know if any of these times would work for your schedule! Typically, sessions are 45-minutes, but for the first session we like to slate a longer window so that I can explain clinic procedures and orient you to the consent documents, which I will send once I hear back from you about timing!
LIST POSSIBLE TIMES HERE
Thank you, I look forward to hearing from you soon!
Best,
Your Name
---After you’ve heard a response---:
Hello [patient name],
Thank you for getting back to me, INDICATE APPOINTMENT TIME sounds great! I am attaching three important documents that I would like for you to please review, sign, and email back to us in advance of our meeting (attach consent documents covering psychotherapy, telepsychology and email). I will review the content of these documents and answer any questions during our meeting!
A few minutes prior to the meeting, go to this link () on any webcam-enabled device (desktop computer, laptop, tablet, smartphone, etc.). This will admit you to a virtual waiting room. Do you mind sending me your phone number as well? I like to have a back-up plan, just in case. So far, doxy.me has worked really well, but any type of technology presents opportunity for technical issues.
Lastly, in the future, I will contact you through my university email address (grp5048@uncw.edu) rather than this UNCW GPAC email address. I also have a google voice number where you can reach me, if necessary: INDICATE NUMBER.
Let me know if you have any questions. Looking forward to seeing you on DATE/TIME of appt!
Best,
Your Name
[pic]
2. Create a folder for this pt. on arcshare and document email exchange in a note for the patient’s file.
3. INTAKE SESSION. Sessions will take place on Doxy.me (your personal link).
a. Supervision: You will start the session by introducing yourself, explaining your trainee status and the supervision model of the clinic (give name of supervisor).
b. Consent: Go through the three consent documents (psychotherapy, telepsychology, and email) and clarify clinic processes and address any questions the patient may have. Make sure they have signed.
c. Fees: Explain that we are currently not charging for sessions, though fees will be re-evaluated in 2021 and will eventually resume ($40 per session, unless fee reduction offered by the director of the clinic).
d. Confidentiality: Explain limits to confidentiality before beginning the intake assessment.
e. Assessment: Work through “Adult Intake Interview_9.2020”
f. Homework: If appropriate, assign between-session homework (self-monitoring form)
[pic]
4. Document content of this visit in an Intake Note (on arcshare)
[pic]
5. Prepare information to present case in supervision
6. Next session should start the SCID (found in “Intake Assessments” folder; 1-3 sessions)
7. For further session documentation, follow “Progress Note” template (arcshare)[pic]
Authorization for Disclosure of Information to/from
UNCW General Psychotherapy & Assessment Clinic
Client’s Name: _________________________ Client’s Date of Birth: _________________
I hereby authorize the UNCW General Psychotherapy & Assessment Clinic to disclose to and/or obtain from:
_________________________________________________________________[Insert Name of Person or
Organization] the following information about the Client named above:
(Client or parent/legal guardian should initial each item to be disclosed)
____ Assessment ____ Educational Information
____ Diagnosis ____ Discharge/Transfer Summary
____ Psychosocial Evaluation ____ Continuing Care Plan
____ Psychological Evaluation ____ Progress in Treatment
____ Psychiatric Evaluation ____ Demographic Information
____ Treatment Plan or Summary ____ Psychotherapy Notes
____ Current treatment update ____Medication Management Information
____Presence/ Participation in Treatment ____ Nursing/Medical Information
____Other______________________ ____Other____________________
Contact Information: The stated person/organization may be contacted by:
Phone: ____________________________________________________________________
Email: ____________________________________________________________________
Mail: _____________________________________________________________________
Other:_____________________________________________________________________
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to UNCW GPAC at gpac@uncw.edu. I understand that the revocation will not apply to information that has already been released in response to this authorization.
Re-release: If the person/organization authorized by this form to receive your information is not a health care provider or otherwise subject to federal or state health privacy laws, the information they receive may lose its protection under privacy laws, and they may be permitted to re-release your information without your prior permission.
Expiration: Unless sooner revoked, this authorization expires in one calendar year from the date signed or as otherwise indicated:__________________________________________.
I will be given a copy of this authorization for my records.
_____________________________________________________________________________
Signature of Client, or Parent/Legal Guardian if under 18 Date
_____________________________________________________________________________
Print Name of Client Print Name of Parent/Legal Guardian if under 18
_____________________________________________________________________________
Signature of Staff Witness Date
|Assess suicidal desire and ideation: | |
| | |
|*1. Have you been having thoughts of suicide? (thoughts of killing yourself?) Tell me about | |
|that. | |
|a. How often? | |
|b. How long lasting? | |
| | |
| | |
|*2. Do you think about wanting to be dead? | |
|a. How often? | |
|b. How long lasting? | |
| | |
|Assess Resolved plans and preparations: | |
| | |
|*3. Have you attempted suicide in the past? Did you hurt yourself with the intent to die? (If| |
|yes: How many times? Methods used? What happened [outcome, severity]? If more than one | |
|attempt: When was your most recent suicide attempt…in the last two years?) | |
|4. How strong is your intent to kill yourself… [e.g., current, next week, past week]? 0 = no | |
|intent at all; 10 = definite intent | |
|*5. Do you have any plan(s) for how you would kill yourself [detail, specificity]? If no: | |
|Have you ever had a plan to kill yourself? | |
|6. Do you know when you expect to use your plan? Do you think you’ll have an opportunity to | |
|kill yourself? | |
|7. Have you acquired means for use in a suicide attempt? [e.g., pills, gun, etc.] | |
|8. Have you made preparations for a suicide attempt? [e.g., buying pills, giving away | |
|personal items, suicide note] | |
| | |
|Assess Other Risk Factors | |
| | |
|*9. Have you ever intentionally caused yourself physical harm by cutting, burning, or other | |
|means, without the intent to die? | |
|*10. Is there any history of self-injury or suicide in your family? | |
|11. Do you feel confident you could attempt suicide? Do you feel afraid to die? 0 = not at | |
|all afraid; 10 = very afraid | |
|*12. Do you feel connected to other people? Do you live alone? Do you have someone you can | |
|call when you’re feeling badly? Who? | |
|*13. Sometimes people think: “the people in my life would be better off if I were gone.” Do | |
|you think that? | |
|*14. Do you feel hopeless? Tell me about that. | |
|*15. Has anything especially stressful happened to you recently? | |
|*16. When you’re feeling badly, how do you cope? Sometimes when people feel badly, they do | |
|impulsive things to feel better. Has this ever happened to you? [e.g., cutting your skin, | |
|drinking alcohol, running away, binge eating, promiscuous sex, physical aggression, | |
|shoplifting]. | |
|17. Other warning signs: 1) agitation, 2) social withdrawal, 3) insomnia/nightmares, 4) | |
|marked irritability | |
|18. Consider past/current psychopathology e.g., Major Depression, Bipolar, Borderline | |
|Personality, Schizophrenia, Eating Disorder | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| |Actions taken: |
| |( Will continue to monitor regularly; |
| |( Given emergency numbers (incl. 1-800-273-TALK) |
| |( Scheduled mid-week phone check-in; |
| |( Means safety for any form of self-injury or plan |
| |( Provided info about adjunctive treatment; |
| |( Safety Plan/coping card |
| |( Consulted Supervisor/Colleague |
| |( Other: _____________________ |
IN THE EVENT OF EMERGENCY
Always have client’s address accessible during telehealth sessions in case crisis services need to be mobilized.
Numbers:
• 911
• Mobile crisis (not as immediate as 911)
o New Hannover (two numbers): 1-866-437-1821; 1-844-709-4097
• Trillium general health resources 1-877-685-2415
• Wellness check (call 911, but say following: “this is not an emergency, I would like to order a wellness check”)
Should a mental health emergency arise during a telepsychology session with a client, the following steps should be taken:
1. Conduct a thorough risk assessment using the Joiner et al. (1999)/Chu et al. (2015) interview (this interview can be adapted for homicidality), and take actions indicated based on the client’s level of risk.
2. Safety plan with the client if appropriate. Email a copy of the safety plan to the client following session and document it in your note.
3. If you assess the client to be at imminent risk of suicide or homicide, do one of the following depending on how imminent the crisis is:
1. Initiate a phone consultation with your supervisor (or any of the licensed supervisors on the supervisor contact list). To initiate this call, the clinician should stay in the telepsychology (Doxy) session while disabling the video feed and muting the sound. This will allow the clinician to watch and listen to the client while consulting with the supervisor. Additionally, the supervisor can be brought into the call via Doxy.
2. If the client is in immediate danger (e.g., informed you that they just made an attempt or are imminently about to make an attempt), bypass step (a) and either call emergency services such as 911 and/or instruct the client to contact emergency services while on the telepsychology platform, whichever is indicated.
i. The clinician should have confirmed the client’s address at the start of session, and this address can be provided to emergency services to locate the client.
ii. Furthermore, the clinician will have obtained an emergency contact from the client during informed consent. This individual can be contacted in the event of an emergency.
Should a medical emergency arise during a telepsychology session with a client, the following steps should be taken:
1. If the client is lucid and able to talk, keep the client as alert and engaged as possible. Ask questions about any preexisting medical history that may explain symptoms.
2. If the client appears to have suffered a sudden medical emergency that has caused him/her to faint, experience a seizure, or become otherwise unconscious, call emergency services such as 911 immediately and inform them of the client’s location that was gathered at the start of session, the symptoms you observed, and any relevant medical history of which you are aware.
3. Contact the client’s emergency contact that was provided in the telepsychology consent form.
All crisis occurrences should be promptly communicated to the supervisor and documented appropriately in the progress notes.
-----------------------
Risk category (circle):
low moderate severe extreme
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- introducing the javamail api nakov
- broker business plan template msm
- the number of listing your office has will directly
- about bowles
- cst l3 tutor guide cpcab
- i introduction
- identifying customers within the federal government
- recruiting resources how to recruit and hire better
- visit us at www
- sample new client welcome letter
Related searches
- how do i sell stocks i own
- i ask or i asked
- synonyms for i believe or i think
- i choose or i chose
- i think i found the one
- i bet or i ll bet
- humss cw mpig i 11 humss cw mpig i 12 humss cw mpig i 13
- i took a deep breath and listened to the old brag of my heart i am i am i am
- i feel like the things i should say are the things i can t say
- i have loved words and i have hated them and i hope i have made them right
- i looked and looked at her and i knew as clearly as i know th
- i e 577 02 9006 yah shua 577 02 9006 holy spirit i i e yah shu