Theory and Practice of Contemporary Psychotherapies

Mental Health Intake Assessment and Informed Consent Video Transcript

If you're worried about your paperwork being reviewed in an audit or by your own client or a lawyer, I have one quick tip that's going to help you feel a lot better about your paperwork. One of the most important things you can do that's often overlooked by therapists is document getting informed consent at the beginning. Now I don't mean getting your intake forms signed. Most people are really good about that. Even if you don't review the intake forms with your clients, most people are pretty good about getting them signed. So firstly, you do want to actually review the forms with your clients.

Make sure that you ask your clients if they have any questions, highlight important topics like your cancellation policy and limits to confidentiality, anything that could potentially become a problem later on. Now informed consent is a fluid process. It's not a one-time thing. So if you miss something, not a big deal, you can just address it later on, any other time in any other session. However, it's not good enough to simply talk to your clients about informed consent and have them sign the form. You also want to document it in your intake note.

So when you write your very first progress note about the first session you had with your client, you also want to write something like, "Reviewed intake packet with client. Reviewed limits to confidentiality, potential benefits and drawbacks of treatment. Discussed fees and cancellation policy. Reviewed limits to confidentiality with adolescent and parents." And lastly, "And obtained consent for treatment." So you might have other things in there that are also important to note. It all depends on your session, but the big thing is to make sure you've also documented that you did review the forms with your clients and you got their consent to treat them. If you're looking for more help with your intake paperwork, then you can check out my free private practice paperwork crash course. In there, I go through intake paperwork and all the different forms you need for your intake packet. So click below and check it out.