First Session

Introduce yourself and the intake process to your client. Use a client-centered approach to explaining the forms in a way that makes them easy to understand. 

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Bring the following paperwork to your first meeting

(All paperwork is available in the Chart Room or click on link)

• Disclosure and consent form 

• Notice of Privacy Practices

• Release of Information (optional)

• Payment Form (for all clients & groups (except school))

• First Session Handout

• Mental Health Intake Form 

• Also recommend: Columbia Suicide Screening Rating Scale (CSSRS), Safety Plan Template, and the Life Events Checklist (LEC-5) 

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Forms are also available in Spanish HERE

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When providing services virtually, all clients should receive these documents via Apricot Connect to gather electronic signatures. Instructions are HERE . However, you should still go over the forms carefully with your client, even if they have already signed them by your first meeting via Apricot Connect. 

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Important information to review in your first meeting:

 

Disclosure and consent
Explain the different sections of the disclosure and consent form, with special emphasis on these issues below. Be clear about the information you provide, and ask your client if they have any questions. 

 

Make sure to address these issues: 

1. Therapists hold client’s confidentiality with these exceptions: 

• Suspected abuse, past or present, of a child currently under the age of 18 

• Suspected abuse of elders or dependent adults

• Intention of serious harm to self or others

• Court order for therapist to release records or testify

• Section 215 of the Patriot Act precludes therapists from informing clients  regarding requests for and the release of records requested by the FBI

• Any disclosure of accessing, streaming, or downloading material where a child is engaged in an obscene sexual act

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2. For school based clients, keep in mind the education code 48920. This code requires immediate report to local law enforcement when you become aware of the following:

• Assault or battery as defined by penal code 245 

• Student is in possession of any drug, alcohol, or intoxicant including marijuana at school 

• Student is in possession of or is selling any narcotic or controlled substance at school

• Student is in possession of a gun at school

• Student is in possession of an explosive at school (ammunition does not meet  the definition for explosive unless it has been made into an explosive device)

 

Schools prefer that you report to the school administrator (principal).  However, you should use your judgment and do what is best to ensure the immediate safety and confidentiality of everyone involved. 

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* Federal law prohibits schools from knowing about drug treatment that occurs both on and off campus. 

*These limitations must be explained in order to obtain informed consent. 

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3. Release of Information: Clients can also waive their right to confidentiality by signing a Release of Information (ROI) which is a legal document that allows the therapist to share information with a designated party. All school based clients need ROIs signed for their school. It is recommended that an ROI be signed for the district and not just the school as this covers additional school staff, such as school psychologists or personnel associated with the school district.

 

3. Your Status: Interns need to clearly explain their intern status and inform clients of their supervisor’s information. 

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4. Mental Health Intake: All individual clients, new and returning, need to complete the intake form. Use your clinical judgment when completing this form. If the session is taking a long time, you can complete the intake in two sessions. 

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5. If the client is at risk of suicide, complete the CSSRS screening form and create a safety plan. 

 

How to assess for suicide during an intake:

Risk assessment is a part of the intake paperwork. Interns should assess for risk using the same skills learned on the crisis line. Be clear and direct, and explain to clients that assessing for risk is part of your role as a therapist. If a client presents with immediate risk, notify your supervisor and the clinical director. If a client identifies any past risk, work with your client to create a safety plan.

 

Use the CSSRS as a guide. Risk identified in school based clients should be discussed with your supervisor, to determine next steps. 

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Prompts to support assessing for risk: 

1. Have you had any thoughts about hurting yourself or hurting someone else?

2. How recently have you had these thoughts? When was the last time you had them? 

3. Did you follow through on these thoughts? 

4. Do you feel as though you are able to manage these thoughts? 

*If yes, ask them how they manage the thoughts and create a safety plan listing these behaviors.

*If no, assess if there is a plan and means, and contact your supervisor and clinical director for consultation on next steps. 

 

Forms that require a client's signature: 

• Consent (mandatory)

• Privacy practices (mandatory)

• Release of Information (ROI) (optional)

• Permission to Record (optional)

• Safety plan (if possible) 

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At the end of the intake session with new clients, offer the client receipt of the note of privacy practices (can email if client is being seen virtually). 

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Hard copies of the consent, note of privacy practices, ROI, CSSRS, and safety plan go into the client's chart along with the paper copy of the intake. The intake is also entered into Apricot in the “Participant Profile” section. 

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The first session, and all subsequent contacts with the client, must be documented in a progress note in Apricot.