First Session
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Item description
First session: initial documents, what to cover, documenting in Therapy Notes
Matching of Clients
Who Our Clients Are
Clients served: ages 5+ ; Each therapist determines the age range they are comfortable working with.
Limitations to Service
Clients DMHS is unable to serve: Clients where substance use is the primary focus of treatment, or a physical dependency may require a detox program; Clients with active psychosis; Clients who require intensive medication management
Services Provided
DMHS provides individual, family, group, and couple therapy. Each therapist determines what services they are comfortable providing.
Intakes
Intakes have 2 meanings at Droste: 1) Intake refers to the initial phone discussion (30-45 mins, roughly) by either a clinical intern on staff or Sarah, and 2) Intakes refer to the first session with the selected therapist that we document in TherapyNotes. When you are assigned an intake session, you will receive an email with the client’s name and contact information as well as any other pertinent information you may need. Contact the client within 48 business hours to set up an intake. When you have completed the intake, please send the intake and any supporting documentation (for adults, the ASSIST, AUDIT, and C-SSRS) to the Executive Director (Sarah) or Intake Coordinator via email.
For Adults, we use 3 assessments: Columbia Suicide Severity Rating Scale (C-SSRS), Alcohol Use Disorders Identification Test (AUDIT), Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).
For Adolescence, we use: The CRAFFT in the first session, kids/teens get the CSSRS in the first session. Intakes with people under 18 are generally done with the parent.
Preferences will be matched according to availability, CL preference, and ED’s clinical judgment. Once a match is made, The ED/Intake Coordinator (Sarah) emails the client (and CC’s assigned therapist) with all onboarding info including their TherapyNotes login. ED (Sarah) will then ‘assign’ the client to a therapist in TherapyNotes.
Scheduling Clients
Virtual sessions can be facilitated using (in order of preference) TherapyNotes or Google Meets.
Never assume the client is going to meet you at the same time next week. Even if the client has a standing preference (i.e, Tuesdays at 10am) we never assume that preference as a standing order. Always confirm the next session.
Please note: TherapyNotes and Google Meets are all HIPPA compliant. Facetime is not, so please avoid scheduling sessions on Facetime.
Each Platforms’ Unique Benefits:
TherapyNotes is the most secure/integrated but doesn't have chat function or whiteboard functionality.
Google Meets is your unique account so no scheduling concerns, also has whiteboard/chat/functionality for working with kids/adolescents.
Engaging with children over virtual platforms: prepare activities in advance and coach parents on any set-up that may be necessary.
In-person Sessions: Rooms are communal at DMHS. If you need a room for a scheduled session, you must email the Business Administrator Joanne DeLuca , j.deluca@drostemhservices.org to reserve a room.
If a client cancels or your schedule changes, inform the Business Administrator.
Onboarding Clients
TherapyNotes
There are several nuances to consider with the structure of TherapyNotes. An example: If you are working with an adolescent or a child with a cell # and/or email address, their number will be listed in a contact bar under information. However, the Parent’s email is used in the onboarding email inviting them to TherapyNotes, etc. Be mindful of whose address you are using when reaching out.
New Clients
All new clients should have completed and uploaded:
Client Contact Form: optional form if they want to provide emergency contacts
COVID Tx Disclosure Form: for clients who started between 3/2020 and 8/2023 this form was a requirement. As of Aug 2023, public health regulations shifted this requirement to be a health and safety notification of disclosure. This form is now a disclosure of risks for in person sessions. See Welcome Packet HERE.
Notice of Privacy Practices: outlines privacy practices of DMHS
Fee Acknowledgement: required for any client self-paying (not required of grant clients)
Payment Authorization: required for any client self-paying, even if they are intending to pay by zelle, check, or cash (not required of grant clients)
PCL-5: required at intake and every 6 months thereafter
PHQ-9: required at intake and every 6 months thereafter
If a client is struggling to complete the forms or hasn’t completed them electronically, assist the client in the first session and upload the forms yourself to Therapy Notes.
After the first session, a Treatment Plan and an Intake Note must be completed for each client
Every session thereafter should have a Progress Note completed.
Any contact with a client or collateral should be documented in a Contact Note.
Giving and Receiving Gifts
Droste policy is that therapists should not give client gifts. If there is a unique circumstance with a client where you believe it is in the best interest of the client and the clinical work to give a gift, discuss the situation with your supervisor and the Executive Director.
Droste also recommends that therapists do not accept gifts. This is because giving and receiving gifts can complicate the professional boundaries we are required to uphold by the Code of Ethics. That being said, there are times when accepting a gift from a client is warranted. Droste’s policy, if you do accept a gift from a client, is that the gift should not have significant financial value (think anything over $20) and there should always be a discussion about the gift with the client reiterating professional boundaries.
When you are making your ethical judgment call around deciding if you are going to accept a gift from a client, HERE is a framework to utilize as well as an additional discussion of ethical decision making HERE. Focus on the potential benefits and risks, ask yourself if accepting the gift is inline with our beneficent responsibility, and consider if there could be any harm in accepting the gift. Bottom line: Ask yourself, who benefits?
Further Info & Help with TherapyNotes
→ ‘Profile’ → ‘Help’
Here you will find articles with Step-by-steps of how to do any number of things from syncing your TherapyNotes calendar to preference settings to HIPAA-compliant video sessions to new client set-up & Notes.
YouTube Therapy Notes Videos:
Here you will find a number of helpful step-by-steps on YouTube to further help you acclimate and orient yourself in TherapyNotes. Please note the menu on the right side which will populate all available videos. Just select ‘From TherapyNotes’ tab on the upper right.
Please find links to more Youtube TherapyNotes Training videos below:
Note Template Updates in TherapyNotes
TherapyNotes: Notes
HERE is a youtube of how to write a Note in TherapyNotes.
TherapyNotes offers several robust note templates which are uniquely designed for behavioral health professionals. Each of our templates balance speed, ease-of-use, and clinically-rich, person-centered documentation using combinations of dropdown menus, checkboxes, and text fields to allow you to quickly, thoroughly, and accurately document the services you provide.
In order to create most notes, a corresponding appointment must be scheduled on the calendar. Since TherapyNotes links note templates to the service type you choose when scheduling an appointment, verify that the correct service is scheduled to access proper documentation. At the time of the appointment, a To-Do list item will be generated to remind you to complete the corresponding note. Once the note is completed and electronically signed, you can bill the service to insurance.
Role Required: Any
Understanding Your Clinical Documentation Workflow
In addition to pulling information forward from scheduled appointments, notes also pull information from previous notes to ensure consistency and efficient documentation. In a typical workflow, once a therapy intake or psychiatry intake is scheduled, TherapyNotes prompts you to complete an Intake Note followed by a Treatment Plan, which pulls information such as the diagnosis and presenting problem from the Intake Note. After subsequent sessions are held with the client, TherapyNotes prompts you to create Progress Notes for each session, and the Progress Note will pull information such as diagnoses and treatment objectives forward from the Treatment Plan.
Follow the steps below to learn more about our powerful notes system or click on any of the links below to jump to that section of the article.
Part 1: Set Up Default Note Settings
Part 1: Set Up Default Note Settings
Note: Customization of diagnosis codes can only be completed by Clinical Administrators.
TherapyNotes includes DSM-5 diagnoses and ICD-10 diagnosis codes to identify a client's diagnosis on notes and for insurance billing.
Customize your interventions list
Click the User Icon > Settings > Interventions (under Notes and Coding)
By default, TherapyNotes includes a list of commonly used interventions that are available as checkboxes on Progress Notes. Each Clinician, Intern, and Clinical Administrator can modify their interventions list to reflect the services they provide. The changes made by one user to their interventions list does not affect the interventions available for other users.
To add a custom intervention, type your intervention in the field at the bottom of the Customize Your Interventions dialog and click the Add Intervention button. To remove an intervention, click the X to the right of the intervention.
Choose what your printed notes contain
Note: Only Practice Administrators or Clinical Administrators can complete this step.
Click the User Icon > Settings > Note Settings
Configure what appears in the header of downloaded and printed notes by selecting or deselecting each item. When finished, click the Save Settings button.
Part 2: Creating Notes
Clinical notes require that the corresponding appointment has been scheduled and is in progress or has already occurred. Notes are not available for the appointment until 5 minutes before the appointment start time.
Most non-clinical notes do not require scheduled appointments to be created.
TherapyNotes offers several ways to create a note.
Create a note from your To-Do list
Click To-Do
Your To-Do list in TherapyNotes is an automatically generated list of tasks that need to be completed, including documents to be collected, notes to be written, and billing items to be submitted and reviewed. When a note is ready to be written, an item for the note will be added to your To-Do list. Find the date of service to write a note for on your To-Do list and click the corresponding note link.
Your To-Do list is also available on several additional pages within TherapyNotes, including the Welcome page, the To-Do List tab of your staff profile, and the To-Do and Schedule tab of a specific client.
Create a note from the calendar
Click Scheduling > Click the appointment > Notes tab
Clicking on a past appointment brings up a dialog with access to appointment details, applicable notes, and billing items relevant to the session. In the Notes tab of this dialog, click on the link for the type of note you want to create.
Create a note without an appointment
Click Patients > Patient Name > Documents tab
Not all documentation in TherapyNotes is associated with an appointment. To view all of the note templates that you have access to in TherapyNotes, click the Create Note button. A list of available note templates will appear.
Different note types will be available depending on your role and clinician type (Psychotherapy or Medication Management). Only Clinical Administrators, Clinicians, and Interns assigned to the client plus Supervisors for the assigned clinicians have access to create and view clinical notes, including Intake Notes, Treatment Plans, Progress Notes, Consultation Notes, and session notes for unscheduled appointments. Contact Notes, Missed Appointment Notes, and Miscellaneous Notes may be created by any user.
For more information on note templates and features, read How To: Create a Note.
Part 3: Access Drafts and Completed Notes
If a note is saved without being electronically signed, TherapyNotes saves the note as a draft. An item will be automatically added to your To-Do list for any drafts that you should complete and sign.
To access all notes for a client, click Patients > Patient Name > Documents tab. This tab shows a chronological list of all notes and files for the client.
If a note is still in draft mode, the note will be highlighted in yellow. Access a note by clicking on the note type in the left column or using one of the action icons on the right. Click the pencil icon to edit the note or the cloud icon to download the note as a PDF. To download multiple notes at once in a single PDF, click the Download Multiple link below the list of notes and files and select the notes to download.
When viewing an existing note, a toolbar is available at the bottom of the page. This toolbar includes options to Edit, Download, or Print the note, as well as access to Revision History for the note. Revision History shows you what changes have been made to the note since it was first saved, which is useful for logging addendums to notes while maintaining the original date of documentation in the event of an audit. If you are a Clinical Administrator, you may delete the note from this toolbar.
HERE is a youtube of how to write a Note in TherapyNotes.
TherapyNotes: Opening a Client
Opening a client
Executive Director (Sarah Strole) will add New Patient in TherapyNotes during the intake.
First session is always selected to be an ‘Intake session’ ; not 'therapy session’. This is because we want the system to prompt you to do a Treatment Plan and an Intake Note (this is an important funnel to subsequent progress notes). All subsequent sessions are ‘therapy session’(s).
{Service Codes for sessions correspond to Service Types of sessions.}
What are the Notes I should be making with each client?
Step-By-Step Therapy Notes Walk-through for Documentation
Please note! Do not check the box for ‘Sign this Form’ at the bottom of the Note until you have finished all editing to the note. To save the draft, just leave the ‘Sign this Form’ box unchecked and click Save Draft.
Initial Documents
Our Executive Director (Sarah Strole) sends the applicable initial documents through the TherapyNotes portal when the matching email goes out. If, for any reason, you do not see those documents, please alert the ED (Sarah) asap. Some documents, like the Welcome Packet, require an electronic signature, while others (like the payment authorization CC form; Emergency Contact info) requires information to be entered manually in the portal.
Any assessments sent through TherapyNotes will integrate into the portal automatically once completed. However, other assessments will be conducted outside TherapyNotes. (*Note: We are currently working on an Assessments Guide which will include outcome measures which will integrate into TherapyNotes and other outcome measures which will not. This is meant to give Therapists the option to conduct assessments in session or ask for assessments to be done on the client’s outside time.)
Required ongoing documentation
Treatment Plan
[Note: TP’s must be in place before a progress note can be written]
Progress Notes/Process Notes
You can create Notes for scheduled and unscheduled patients. For Scheduled Patients: (3 possible ways )
1. To-Do → Create Psychotherapy Intake Note.
2. Scheduling page → click the appt → click the ‘Notes’ tab. → then ‘Psychotherapy Intake Note.
3. Patients tab → Patient’s Name → Documents → Create Note; then select type of Note.
For Unscheduled Patients: click Patients, select the patient’s Name, then go to the ‘Documents’ tab and click ‘Create Note’.
Closing a client
Deactivate, Terminate, or Discharge a Client
Verify that the client has no upcoming appointments.
Click Patients > Patient name > Documents tab.
Click the Create Note button and select Psychotherapy Termination Note or Psychiatry Termination Note from the list that appears.
Complete, sign, and save the note
Click HERE for more details.
Billing Settings
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Missed Sessions
Droste policy is that we require 24-hrs notice for a session cancellation. Otherwise we charge the full-session fee. See TherapyNotes Welcome packet. While this is Droste policy, every clinician has discretion to exercise this policy to the extent they wish using best judgment. See Library TherapyNotes Welcome Packet.
Clinicians have flexibility to make an arrangement that makes sense for both client and therapist, bearing in mind healthy boundaries on time and open, direct communication about the arrangement.
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Canceled Sessions
See above. Therapist to use best discretion. Boundaries and communication on this topic is encouraged.
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Therapist Payment
Different rates are set within service codes.
Example Description:
Initial Evaluation 90791 - 60 minutes;
Individual Session 90834 - 45 minutes;
Individual Session 90837 - 60 minutes.
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Ways to Pay
Payment Methods:
1. Checks are payable to Droste Mental Health Services, Inc.
2. Credit card and debit card payment is accepted; there is a $3 processing fee per transaction.
3. Zelle is accepted, please use j.deluca@drostemhservices.org for this transaction.
We are currently only out-of-network so we accept: CC/Debit (includes a $3 surcharge), Cash, Zelle (no Venmo)
Credit card MUST be uploaded into Therapy Notes. This occurs through the client completing the Payment Authorization Form in Therapy Notes sent to them upon matching with a therapist. Each therapist should verify this was completed at the time of the first session. If it wasn’t, walk the client through how to complete it or get the credit card information from the client to enter yourself, or make the client provides this to the Business Administrator to enter. However, please note, regardless of method of payment, a CC is required in TherapyNotes.
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How Fees Are Set
Currently the lowest fee we offer is $70. This is to ensure therapists receive fair compensation at market rate for even those clients at the bottom of our fee scale.
Fees are set using our fee scale. We ask clients for their gross annual income (or for those hourly or contract-based clients, we estimate based on weekly or monthly income) and then let them know where they are on the fee scale. Occasionally we may have clients unable to pay that amount due to extraneous circumstances in which case fees may be negotiated at the discretion of ED, Business Admin, or therapist. It is unusual for fees to be negotiated more than $20 below the suggested amount. However for interns, special circumstances may warrant up to 50% rate reduction.
Currently we operate on the honor system, we do not require proof of income.
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Reviewing/Changing Fees
At a minimum, we ask therapists to review fees annually. Fees should also be reviewed if there is a dramatic shift in client circumstances (ie job loss, promotion, job change).
If you are changing a client fee, please update this in the billing settings tab (link to video), and email the Business Administrator.
Types of Notes
At Droste, we use the SOAP notes structure in TherapyNotes.
What is a SOAP note?
(Subjective Objective Assessment Planning) SOAP notes are intended to capture specific information about a client and certain aspects of the session. SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning). All SOAP notes should be kept in a client’s medical record. You can find more info on SOAP notes HERE.
(S) Subjective statement about relevant client, behavior or status.
Clients, chief complaint, presenting problem, and any other relevant information including direct quotes from the client, Any relevant personal or medical issues that may impact or influence the clients day-to-day routine, A complete account of the clients description of symptoms, Progress from the last encounter
(O) Objective observable, quantifiable and measurable data
Physical, interpersonal, and psychological observations, Verbal nonverbal, Body posture, general appearance, affect and behavior when discussing certain topics or issues, nature of therapeutic relationship, strengths, mental status, ability to appreciate to participate in the session, responses to the process, written materials
(A) Assessment, assimilate S & O section
Use professionally acquired knowledge to interpret the information given by the client during the session, implement critical knowledge and understanding, DSM/therapeutic model, identity, themes, or patterns. Update/include DSM criteria, observations exhibited by the client.
(P) Planning detail the plans for the client
Next steps for upcoming session, stay aligned with overall treatment plan, focus on things both parties have agreed to, note nutritional physical and medical attributes that will contribute to the clients therapeutic goals, note progress or regression. Client has made and treatment include implement implementation details ensure planning is aligned with assessment and direct.
Other templates include:
DAP notes
DAP stands for Data, Assessment, and Plan. DAP notes take the Subjective and Objective sections of a SOAP note and combine them into a single section: data.
D – Data: This section is where you add data from your counseling or psychotherapy session. This could include:
Reason for the visit
Client presentation/appearance
Client mental status
Client reports of current symptoms or important events since the last session
Results of screening or other measures
Interventions applied in session
Client responses to interventions applied
A – Assessment: This section is where you take the data from the first section and apply your clinical judgment to it. This could include:
How the client is progressing
How the client’s status relates to their treatment goals
How the client responded
Changes to the client’s diagnosis
P – Plan: Given the observed data and your interpretation of it, where does treatment go from here? This section could include:
The date, time, and location of the next scheduled session
Homework assigned to the client
Referrals provided to the client
Consultation or other third-party contact planned by the clinician
Changes to the treatment plan based on the client’s progress so far
Additional steps related to the treatment that the client or clinician is expected to take
BIRP notes
BIRP note structure = behavior, intervention, response, and plan. BIRP notes can make your documentation more efficient by boiling down each session to four key questions:
What’s the specific problem to be addressed in this session?
What did the therapist do about it?
How well did that work?
What comes next?
What’s the difference between BIRP notes and SOAP notes?
BIRP notes and SOAP notes are both meant to streamline the note-taking process. BIRP notes focus on describing a session’s theme and overall tone, as well as the behavior of your client, while SOAP notes aim to be more objective and document treatment outcomes and next steps.
Privacy Policies
Noise-canceling sounds machines
There are sound machines located on the floors outside of every office – please use them to ensure privacy. Please remember to turn them off before leaving for the day.
Headphones
Please also headphones for virtual sessions: because sound carries differently through a computer speaker. It is important for privacy considerations to use headphones where possible.
Virtual Sessions
Virtual sessions can be facilitated using Zoom or Google Meets. The agency has a zoom account that can be used to schedule sessions. Log in information is: zoom@drostemhservices.org; PW: Droste2022!
Please check scheduled sessions prior to booking your session to ensure you are not double-booking the zoom account.
Naming convention: [Therapist name] session [client initials]
Engaging with children over virtual platforms: prepare activities in advance and coach parents on any set-up that may be necessary.
Mandated Reporting
Elder Abuse
You can call the New York State Protective Services for Adults Hotline at 1-800-342-3009. You can call 9-1-1 if someone is in immediate danger or risk of harm, or you can call 3-1-1 to report suspicion of abuse to the appropriate authorities.
DV
National Domestic Violence Hotline: 24/7. Languages: English, Spanish and 200+ through interpretation service: 1-800-799-7233
Sexual Assault
Oral reports must be made immediately to the statewide central register of child maltreatment hotline (1-800-342-3720)
Child Abuse
What happens if i’m concerned about a child outside of NY?
Reports of suspected child abuse or maltreatment should be made immediately -- by telephone to the New York Statewide Central Register of Child Abuse and Maltreatment (sometimes referred to as the State Central Register or SCR). Child Abuse Hotline Number: 1-800-342-3720
The Child Protective Specialist who answers your call will ask you for as much information as you can provide about both the suspected abuse or maltreatment and the family about which you are calling.
What happens if I’m concerned about a child outside of the US
Call your local FBI field office or the closest international office. You can also contact the National Center for Missing and Exploited Children at 1-800-THE-LOST.
FAQ
What CPS Can and Cannot do HERE
Mandated Reporting: everyone at DMHS is a mandated reporter. If you suspect abuse (you do not need to have confirmed abuse) in an adult or an adolescent client, you must call the State Central Registry’s Mandated Reporter Hotline 1-800-635-1522.
Mandated Reporting General Info: You do not need the agency or a supervisor’s permission to make this call; in fact, it is your legal and ethical responsibility to make this call regardless of supervisor approval. That being said, supervisors and the Executive Director are always available to support with mandated reporting responsibilities.
Please inform your supervisor and the Executive Director immediately after making a mandated report with the outcome. If a case is accepted, you must fill out and mail a copy of the LDSS-2221A form within 24 hours of making a report.