Welcome to the front lines of client engagement! Getting the paperwork in order might not be the glamorous part of therapy, but it's crucial for creating a smooth and secure therapeutic experience. Before you sit down for your first session with a client, make sure the following documents and forms are complete:

Consent Documents:

Informed Consent, Litigation Limitations, Notice of Privacy Practices, Practice Policies, Telehealth Consent Form

Questionnaires:

New Client Information (Adult/Minor), Standard Intake Questionnaire Template, Good Faith Estimate for Health Care Items and Services - 2023 (if applicable),

Demographics and Credit Card Forms:

Credit Card Information, Demographics Form

Clinician’s Role:

Contact Information: Please ensure that you provide our administrative staff with your client's phone number and email address. This is important for establishing a communication line and confirming appointments.

File Completion: All the above forms and questionnaires must be completed and uploaded into SimplePractice before any sessions can begin. This is non-negotiable and is a part of our compliance protocol.

Billing & Insurance:

Lucky for you, any billing or insurance questions can be forwarded to our administrative team. Discussing billing and insurance matters with clients creates a dual relationship that can muddy the therapeutic waters. This means you get to focus on what you love—being a compassionate and effective therapist—while we handle the number-crunching and paperwork. So go ahead, let us deal with the admin stuff; you're free to create meaningful connections and transformations with your clients.

Managing your appointments is a breeze with the SimplePractice calendar. For those working from our Riverside and Corona locations, remember that specific slots are designated for in-person sessions. Want to open up an available slot for new clients? Simply block the hour as "ROK" on the calendar. This will signal to the Admin Team that it's OK to schedule a session in that time slot.

Get Interactive:

If you set your appointment to 'Available' within the SimplePractice calendar, clients can also request a session themselves. However, it's important to guide current clients on how they can take advantage of this feature. Communicate that they can request appointments via their client portal, accessible at http://mcounseling.clientsecure.me at any time.

Pro Tip:

Sync your SimplePractice calendar with your personal digital calendar to streamline your day and ensure no appointments overlap.

By effectively managing your schedule, we maintain a cohesive, professional environment that respects both your time and that of our clients.

Cancellations & Rescheduling: Setting Boundaries and Expectations

Our practice operates under a strict 24-hour cancellation policy. It’s essential that you make clients aware of this policy upfront to prevent any misunderstandings down the line. All cancellations, regardless of the reason, should be documented within SimplePractice.

Cancellation Policy Summary:

Advance Notice: Clients must cancel or reschedule 24 hours in advance to avoid being charged the full session fee.

Session Duration: Our standard therapy session is 50 minutes. However, if a client wishes to extend or shorten this, such modifications must be discussed and agreed upon in advance with you, the therapist.

Late Arrivals: If a client is late, the session might be cut short without altering the session fee.

Frequent Cancellations/Missed Appointments: Having three or more cancellations in 6 months or two consecutive no-shows will lead to the termination of treatment. Clients must notify their therapist 24 hours in advance to cancel or reschedule, even for recurring appointments. Failing to do so will result in a second No Show/Late Cancel charge at the full fee rate.

Communication is Key:

You are responsible for communicating this policy clearly to your clients. Please note that unless informed otherwise by the administrative team, you will be financially responsible for your own cancellation fees. Make sure to discuss this policy in your first session and provide written copies for your clients as well.

By adhering to these guidelines, we maintain a professional atmosphere and ensure that everyone’s time—including yours—is respected.

Clinical Notes: The Backbone of Effective Care

All session notes must be entered into SimplePractice within 48 hours of a client appointment. Templates for various note types (SOAP, DAP, etc.) are readily available to make this process as streamlined as possible.

Diagnosis Provided: It is crucial for therapists to provide a provisional diagnosis within 24 hours following the first session with a new client. A provisional diagnosis is an initial clinical assessment that offers a temporary diagnosis based on the available information; it can be updated as more data is gathered in subsequent sessions. Providing this diagnosis promptly is not only important for guiding the course of treatment but is also a requirement for billing purposes. Insurance companies often need a diagnosis code to process claims, and delays in providing this information could lead to delayed or denied payments.

For Associate Marriage and Family Therapists (AMFTs), once a provisional diagnosis is entered into SimplePractice, consultation with a clinical supervisor is strongly advised to confirm or refine the diagnosis. This ensures that the treatment plan aligns with the most accurate clinical understanding of the client's needs.

Keep in mind that a timely and accurate diagnosis is not just a formality; it's an integral part of effective and ethical client care.

For Associate MFTs: Please forward your completed session notes to your Supervisor before the next scheduled supervision meeting.

Templates and Customization: We offer a variety of templates to suit different session types. If you find that a template you wish to use isn't available, you're welcome to request a new one from our administrative team.

Special Note for Kaiser Permanente Clients: Licensed clinicians should be aware that clients from Kaiser Permanente require a weekly TPI assessment. It's crucial to follow protocol for these specific notes.

Client Records: Everything in its Right Place

Make sure that all client paperwork—be it treatment plans, signed consent forms, or assessments—are uploaded into their SimplePractice profiles. This is non-negotiable and a cornerstone of our client care policy.

Additional Notes and Communications:

Administrative Notes: Stay in the loop by regularly checking administrative notes attached to your clients' files in SimplePractice. These could contain important scheduling, billing, or other procedural information.

Chart Notes: If you need to make notes on client communication or other important details that don't fit into a clinical progress note, use the Chart Notes feature in SimplePractice.

Training & Guides:

If you would like additional training or have questions about documentation, we have a comprehensive record-keeping and note-writing guide available. Familiarize yourself with this guide to enhance your clinical documentation skills.

By rigorously following these documentation and record-keeping guidelines, we uphold the highest standard of client care and organizational efficacy.

Staff Newsletter: To supplement these meetings, we will be sending out a monthly newsletter. Make sure your email settings allow for receiving these newsletters, so you're always up to date with the latest information.

Supervision: Learning Never Stops

For our pre-licensed therapists, attendance at weekly supervision sessions is mandatory. The number of supervision units you'll need depends on your client caseload: a minimum of one unit for up to 10 clients, and a maximum of two units for 11 or more clients. Keep an eye on your SimplePractice calendar for available slots and locations. It’s your responsibility to maintain updated weekly logs for licensure tracking.

Inter-Office Communication: Safety and Ease

We exclusively use SimplePractice’s internal messaging platform for day-to-day communications, especially when discussing anything that identifies a client. This platform is HIPAA compliant, ensuring we maintain the utmost confidentiality and security in our client interactions.

HIPAA Compliance: All our platforms and communication methods are geared towards maintaining HIPAA compliance. This is not just a legal requirement but a cornerstone of our practice’s integrity.

Voxer & Email: Admin Team at Your Fingertips

For direct lines of communication with the admin team, Voxer and email are your go-to channels. Text messages and phone calls are also options but use them at your discretion, depending on the urgency and nature of the matter you're dealing with.

With effective communication at the core, we can provide an outstanding level of care to our clients while fostering a work environment that is both efficient and nurturing.

IT Issues: Don't Panic, Reach Out

If you encounter any problems with SimplePractice or any other software, don't hesitate to report these directly to our admin team. For quick troubleshooting, we highly recommend checking out the Simple Practice Facebook Community Page, which is a great resource for common issues and fixes.

Equipment & Supplies: Your Work, Your Way

We know how important it is to have the right supplies, both at our physical locations and for our virtual therapists. If you need anything, from office basics to specialized therapy tools or games, please email the admin team or text Reba to make your request.

Budget Allocated: We've set aside a budget specifically for office supplies. We want to ensure that you're well-equipped with what you need to offer the best service possible.

Delivery Timeline: After making your request, please allow 3-5 business days for most supplies to arrive. Some specialized items may take longer, so plan accordingly.

We highly encourage you to request any items you might need. The goal is to make sure you're equipped to provide the best care to our clients.