Essential Private Practice Paperwork

$150.00 for Each Set of Paperwork

Whether you have owned a practice for many years or are considering starting your own, paperwork that is up to date, HIPAA compliant, and protects your practice from ethical concerns is essential for working with clients.

Each set of paperwork has been compiled, developed, and continually revised since 2007 when Dr. Johnson began the Center for Counseling and Family Relationships. All documents included in the portfolio are sent electronically in PDF documents.

Starter Set One for Clients:

Our Intake Paperwork

Our Intake Paperwork includes:

Insured’s Information and How to Check Benefits

Client Information

Household Information

Medical History

Cancellation Policy and Credit Card Information

Our Fee Policy

Assignment of Benefits

Other Fees

Grievances

Emergencies

Limits of Confidentiality

Acknowledgement of Review of Privacy Practices

Communication Authorization

Our Policies and Procedures

This two-page document includes how we handle:

Session times

No-Shows, Late Cancellations, and Scheduling

Late Arrival and Scheduling

Balances and Credits

Parent Updates Before child Sessions

Release of Information

Wait List

Emergencies

Continued Care

Limits of Confidentiality

Notice Of Privacy Practice:

This form includes HIPAA and PHI information for CCFAM as required by law.

Release of Information for Adult

This form is a standard release for an adult client including: who to release to, information to release, the purpose of the release, and the ability to revoke consent.

Release of Information for a Minor

This form is a standard release for a Minor Client including: who to release to, information to release, the purpose of the release, and the ability to revoke consent.

 

Advanced Set Two for Clients:

First Appointment Checklist

This checklist is one page and goes through all the details and reminders of what a client needs to know and paperwork to bring to their initial appointment, including arranging childcare for their children and custody paperwork for minor children.

Parent Letter of Participation

When required by divorce decree, this form about our practice is given to the Custodial Parent, who has sought counseling for their child, to share with the child’s other Custodial Parent, who needs to be informed of counseling.

Checklist of Concerns for Child

This checklist is one page and includes concerns of parents and allows them to select symptoms and behaviors of their child. It also includes questions about exercise, sleep, screen time, and devices.

Client History for Teens Only

This history form is several pages and includes the teen’s perspective on:

the need for counseling

medical and behavioral symptoms they are concerned about

information about their family

alcohol and drug history

school and friends

their self-description

daily life (exercise, sleep, screen time)

Checklist of Concerns for Adult

This checklist is one page and includes: medical and behavioral symptoms along with questions about exercise, sleep, and screen time.

Adoption Background Information

This form is one page and includes questions about the Birth Family and the openness of the adoption.

Foster Care Background Information

This form is two pages and includes Birth Family History and Foster Care Placement History.

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