Documentation Timeline

Timeline​

• Receive client assignment and contact within 3 business days. 

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• Make 3 contact attempts within 2 weeks. Document all contact attempts and responses in the Inquiry Notes section of the Participant Profile. ​​

• If you do not receive any response from the client, add an Inquiry Closure Date and let the Clinical Coordinator know so that you can receive a new assignment. ​

• If you hear back from the client, schedule the first session. Use Google Calendar to reserve counseling rooms at CSS or to let others know about home visits. 

• Get paperwork ready for your first session.

  • Disclosure and consent form

  • Notice of privacy practices

  • Receipt of privacy practices

  • Release of information form

  • Permission to record

  • Payment form

  • Mental health intake form

  • CSSR, safety plan template, and LEC-5

• In your first session, review all paperwork and start the mental health intake form. If necessary, also use the CSSR, safety plan template and LEC-5.
   

• After your first session, write a progress note using BIRP template
   

• Within 30 days, complete assessment
   

• Within 60 days, complete treatment plan​​​

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Intakes and Client Openings:

A client is considered open and an official CSS client once the consent forms are  signed. Once open, all contacts with clients should be documented in a progress note. Best clinical practice is to have all progress notes completed within 72 business hours.  All notes are due at the end of the month for tracking purposes. 

 

Assessments - Within 30 Days:

The clinical assessment needs to be completed thirty (30) calendar days after the date of intake and submitted to the Director or Coordinator for approval. Clinical assessments are not done interview-style, but are woven into the first sessions with the client. Familiarize yourself with the assessment questions and plan to ask the questions in a way that feels natural to you. Best practice is to complete a genogram or family map during the first few sessions to understand the client’s lived experience and support systems. Other interventions could be a timeline of the client’s life before therapy or the Tree of Life activity.

 

Examples of useful open-ended questions: 

• What are you hoping to happen by coming to see me? 

• What should I know about you in order to be useful? 

• Who is important in your life? 

• What has been especially hard in your life? 

• How do you manage when things become hard? 

 

Treatment Plans - Within 60 days:

Working collaboratively with the client in this manner helps determine the treatment goal, which leads to the treatment plan. The client’s treatment plan is a shared document that outlines what the client sees as the problem and what intervention the client and therapist have determined to be useful. These plans outline what the client has committed to do to create change and also what the therapist will do to support that change. Treatment plans can be written with the client in the session, or can be written separately by the therapist with input from the client, but the document needs to be reviewed and signed by the client and/or their caregiver if they are under 18 years of age. If treatment goals change, a new treatment plan should be written and a new signature should be obtained. If a new risk is assessed, a new treatment plan should be collaboratively created to address safety, and this new treatment plan should be signed. For example, if your client is psychiatrically hospitalized, create a new treatment plan with goals to specifically address the factors that caused them to be hospitalized. 

 

The treatment plan flows from the identified needs in the intake and the assessment. This is what is known as the clinical loop. The treatment plan should have two treatment goals that are developed collaboratively with the client. Treatment goals should be focused on identified mental health needs. Treatment plans need to be completed within sixty (60) days of intake. Treatment plans are completed in Apricot and then printed out in order to review with the client. A client signature is best practice. If a client declines to sign or you are unable to obtain a signature, document appropriately on the treatment plan. 

 

Transition and Aftercare Forms (endings with clients):

The transition form is completed at the end of services. It is completed once the client ends or when the clinician leaves the agency. This form tracks the reasons services were ended and the progress made by the client. This form should be completed within 7 days of ending services. 

 

There is also an optional aftercare form that is completed in collaboration with the client. The form can be printed out and given to the client either in person or through the mail.

 

Closing Chart Checklist:

Here is information about how to close files by completing Apricot paperwork and chart room files when ending with a client.

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***Notify Clinical Coordinator that client’s chart is closed***