The Clinical Documentation Sourcebook

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.

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 (