All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Table of Contents:
Preface to the Fourth Edition ix Introduction xi Chapter 1 Administrative and Intake Forms 1 Introduction Form 1 Screening Information 6 Form 2 Notice of Appointment 7 Form 3 Consent to Treatment and Recipient’s Rights 8 Form 4 Recipient’s Rights Notification 9 Form 5 Financial Policy 11 Form 6 Payment Contract for Services 12 Form 7 Code of Ethics and Mission Statement 14 Form 8 Therapist’s Ethics Statement 15 Form 9 Agreement Regarding Minors 16 Form 10 Preauthorization for Health Care 18 Form 11 Confidentiality Agreement 19 Chapter 2 Forms Designed for HIPAA Compliance 21 Introduction Form 12 Privacy of Information Policies 27 Form 13 Request to Amend Health Records 30 Form 14 Request for Restricted Use/Disclosure of Records 31 Form 15 Request for Alternative Means of Confidential Information 32 Form 16 Release of Information Consent 33 Form 17 Record of Requests for Client Information 34 Form 18 Request for Listing of Disclosures of Client Records 35 Chapter 3 Screening Information 37 Form 19 Mental Health Screening Form 38 Form 20 Substance Abuse Screening Form 39 Form 21 Adaptive Functioning Screening Form 40 Form 22 Learning Disability Screening Form 41 Form 23 ADHD Screening Form 42 Chapter 4 Assessment Forms 43 Introduction Form 24 Initial Assessment—Adult 50 Form 24A Example of Completed Form 58 Form 25 Initial Assessment—Children and Adolescents (<18) 66 Form 25A Example of Completed Form 74 Form 26 Personal History—Adult (18+) 82 Form 26A Example of Completed Form 90 Form 27 Personal History—Children and Adolescents (<18) 98 Form 27A Example of Completed Form 106 Form 28 Couple’s Information Form 114 Form 29 Emotional/Behavioral Assessment 120 Form 29A Example of Completed Form 124 Form 30 Emotional/Behavioral Update 128 Form 30A Example of Completed Form 129 Form 31 Diagnostic Assessment Report 130 Form 31A Example of Completed Form 136 Form 32 Diagnostic Assessment—Lower Functioning 141 Form 32A Example of Completed Form 145 Form 33 Biopsychosocial Report 149 Form 33A Example of Completed Form 152 Chapter 5 Psychological Evaluations 155 Introduction Form 34 Psychological Evaluation—Adult 157 Form 34A Example of Completed Form 171 Form 35 Psychological Evaluation—Children and Adolescents 186 Form 35A Example of Completed Form 200 Form 36 Psychological/Vocational Assessment 214 Form 37 Neuropsychometric Consultation 224 Chapter 6 Treatment Planning Forms and Procedures 231 Introduction Form 38 Individual Treatment Plan 236 Form 38A Example of a Poor Treatment Plan 237 Form 38B Example of Completed Form—Adult 238 Form 38C Example of Completed Form—Children and Adolescents 240 Form 39 Short-Term Therapy Treatment Plan 242 Form 39A Example of Completed Form 243 Form 40 Treatment Review 245 Form 40A Example of Completed form 247 Form 41 Treatment Update 249 Form 41A Example of Completed Form 250 Chapter 7 Progress Notes 251 Introduction Form 42 Progress Notes 258 Form 42A Example of Poor Progress Notes 259 Form 42B Example of Completed Form—Adult 260 Form 42C Example of Competed Form—Children and Adolescents 261 Form 43 Progress Notes—Outline 262 Form 43A Example of Completed Form 263 Form 44 Group Therapy Progress Notes 264 Form 44A Example of Completed Form 265 Form 45 Psychiatric Medication Management Progress Notes 266 Chapter 8 Other Forms Used during the Course of Treatment 269 Introduction Form 46 Referral for Mental Health Services 272 Form 47 Informed Consent for Medication 273 Form 48 Suicide Contract 274 Form 49 Cooperating in Child Rearing 275 Form 50 Couple’s Analysis of Target Behaviors 280 Form 50A Example of Completed Form 282 Form 51 Third-Party Prior Authorization Request for Continued Services 284 Form 51A Example of Poor Authorization Request 285 Form 51B Example of Completed Form 286 Chapter 9 Chart Review and Outcomes Documentation 287 Introduction Form 52 Chart Review 289 Form 53 Utilization Review Committee Guide to Review Charts for Audit 291 Form 54 Utilization Review Committee—Chart Review Summary 295 Form 55 Medical Records Audit Chart 296 Form 56 Statement of Confidentiality for Those Auditing or Reviewing Client Charts 302 Form 57 Outcome Survey for Adults 303 Form 58 Outcome Survey for Children 304 Form 59 Outcome Survey for Families and Relationship 305 Chapter 10 Termination and Aftercare 307 Introduction Form 60 Discharge Summary 309 Form 60A Example of Completed Form 311 Form 61 Termination Letter 313 Bibliography and Suggested Readings 315 CD-ROM Table of Contents 317 About the CD-ROM 319