The Clinical Documentation Sourcebook: A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records, 2nd Edition

by Donald E. Wiger

• ISBN13: 9780471326922
• ISBN10: 0471326925
• Edition: 2nd
• Format: Paperback w/Disk
• Copyright: 1999-01-01
• Publisher: Wiley

Summary

This Second Edition of a successful clinical resource provides mental health professionals with a full arsenal of forms, checklists, and clinical records essential to effective practice management in the managed care era. The paperwork required when providing mental health services in the current era of third-party accountability can be quite daunting. This updated and revised second edition provides sample forms for each step of the treatment process (from intake, to diagnosis and treatment, through discharge and outcomes assessment).

Author Biography

Donald E. Wiger, PhD, is a psychologist with a successful private practice. He teaches graduate courses at the Minnesota School of Professional Psychology. Through his company, CPS Seminars, he also conducts workshops training other mental health professionals in psychological assessment and clinical documentation.

Table of Contents

Introduction	xv
Chapter 1 Intake and Termination Forms and Procedures	1.1	(1)
Initial Client Information Form
Form 1 Sample Form	1.9	(1)
Form 1A Example of Completed Form	1.10	(1)
Financial Policy Statement
Form 2 Sample Form	1.11	(1)
Payment Contract for Services
Form 3 Sample Form	1.12	(1)
Limits of Confidentiality Form
Form 4 Sample Form	1.13	(2)
Preauthorization for Health Care Form
Form 5 Sample Form	1.15	(1)
Release of Information Consent Form
Form 6 Sample Form	1.16	(1)
Suicide Contract
Form 7 Sample Form	1.17	(1)
Discharge Summary Form
Form 8 Sample Form	1.18	(2)
Form 8A Example of Completed Form	1.20	(2)
Termination Letter
Form 9 Sample Form	1.22
Chapter 2 Assessment for Counseling Forms and Procedures	2.1	(1)
Initial Assessment Forms
Form 10 Sample Form--Adult	2.11	(8)
Form 10A Example of Completed Form--Adult	2.19	(8)
Form 11 Sample Form--Child	2.27	(8)
Form 11A Example of Completed Form--Child	2.35	(8)
Biographical Information Form
Form 12 Sample Form--Adult	2.43	(7)
Form 12A Example of Completed Form--Adult	2.50	(7)
Form 13 Sample Form--Child	2.57	(5)
Form 13A Example of Completed Form--Child	2.62	(5)
Personal History Forms
Form 14 Sample Form--Adult	2.67	(8)
Form 14A Example of Completed Form--Adult	2.75	(8)
Form 15 Sample Form--Child	2.83	(8)
Form 15A Example of Completed Form--Child	2.91	(8)
Emotional/Behavioral Assessment
Form 16 Sample Form	2.99	(4)
Form 16A Example of Completed Form	2.103	(4)
Emotional/Behavioral Update
Form 17 Sample Form	2.107	(1)
Form 17A Example of Completed Form	2.108	(1)
Biopsychosocial Report
Form 18 Sample Form	2.109	(3)
Form 18A Example of Completed Form	2.112	(3)
Diagnostic Assessment Report
Form 19 Sample Form	2.115	(6)
Form 19A Example of Completed Form	2.121	(6)
Diagnostic Assessment--Lower Functioning
Form 20 Sample Form	2.127	(4)
Form 20A Example of Completed Form	2.131
Chapter 3 Evaluation Forms and Procedures	3.1	(1)
Psychological Evaluations
Form 21 Sample Form--Adult	3.3	(13)
Form 21A Example of Completed Form--Adult	3.16	(13)
Form 22 Sample Form--Child	3.29	(14)
Form 22A Example of Completed Form--Child	3.43
Chapter 4 Treatment Plan Forms and Procedures	4.1	(1)
Individual Treatment Plans
Form 23 Sample Form--Child or Adult	4.7	(1)
Form 23A Example of a Poor Treatment Plan	4.8	(1)
Form 23B Example of a Completed Form--Adult	4.9	(1)
Form 23C Example of a Completed Form--Child	4.10	(1)
Short-Term Therapy Treatment Plan
Form 24 Sample Form	4.11	(1)
Form 24A Example of a Completed Form	4.12	(1)
Treatment Review
Form 25 Sample Form	4.13	(2)
Form 25A Example of Completed Form	4.15	(2)
Treatment Update
Form 26 Sample Form	4.17	(1)
Form 26A Example of Completed Form	4.18
Chapter 5 Progress Notes and Prior Authorization Request Forms and Procedures	5.1	(1)
Sample Progress Notes
Form 27 Sample Form	5.9	(1)
Form 27A Example of a Poor Progress Note	5.10	(1)
Form 27B Example of Completed Form--Adult	5.11	(1)
Form 27C Example of Completed Form--Child	5.12	(1)
Progress Notes--Outline
Form 28 Sample Form	5.13	(1)
Form 28A Example of Completed Form	5.14	(1)
Group Therapy Progress Notes
Form 29 Sample Form	5.15	(1)
Form 29A Example of Completed Form	5.16	(1)
Third-Party Prior Authorization Request for Continued Services
Form 30 Examples of Completed Form (Bad P.A)	5.17	(1)
Form 30A Examples of Completed Form (Good P.A)	5.18	(1)
Clinical Outcomes Questionnaire
Form 31 Sample Form	5.19	(1)
Chart Review
Form 32 Sample Form	5.20	(1)
Chapter 6 Relationship Counseling Forms and Procedures	6.1
Marital and Couple's Information Forms
Form 33 Sample Form--Marital	6.4	(5)
Form 34 Sample Form--Couples	6.9	(5)
Analysis of Target Behaviors
Form 35 Sample Form	6.14	(2)
Form 35A Example of Completed Form	6.16	(2)
Cooperating in Child Rearing
Form 36 Sample Form	6.18	(5)
Sharing Your Feelings
Form 37 Sample Form	6.23	(2)
Form 37A Example of Completed Form	6.25
Bibliography and Suggested Readings	B.1
About the Disk	D.1