The Clinical Documentation Sourcebook: The Complete Paperwork Resource for Your Mental Health Practice / Edition 4

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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.

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Product Details

  • ISBN-13: 9780470527788
  • Publisher: Wiley
  • Publication date: 2/2/2010
  • Edition description: New Edition
  • Edition number: 4
  • Pages: 336
  • Sales rank: 302,497
  • Product dimensions: 8.50 (w) x 10.80 (h) x 1.00 (d)

Meet the Author

DONALD E. WIGER, PHD, a psychologist, is director of a mental health clinic in St. Paul, Minnesota. He has taught graduate psychology students for twenty years and provided training seminars to thousands of mental health professionals throughout the United States. He is the author of numerous books, including The Psychotherapy Documentation Primer, Second Edition, also from Wiley.

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Table of Contents

Preface to the Fourth Edition.


Chapter 1 Administration and Intake Forms.


Form 1 Screening Information.

Form 2 Notice of Appointment.

Form 3 Consent to Treatment and Recipient's Rights.

Form 4 Recipient's Rights Notification.

Form 5 Financial Policy.

Form 6 Payment Contract for Services.

Form 7 Code of Ethics and Mission Statement.

Form 8 Therapist's Ethics Statement.

Form 9 Agreement Regarding Minors.

Form 10 Preauthorization for Health Care.

Form 11 Confidentiality Agreement.

Chapter 2 Forms Designed for HIPAA Compliance.


Form 12 Privacy of Information Policies.

Form 13 Request to Amend Health Records.

Form 14 Request for Restricted Use/Disclosure of Records.

Form 15 Request for Alternative Means of ConfidentialInformation.

Form 16 Release of Information Consent.

Form 17 Record of Requests for Client Information.

Form 18 Request for Listing of Disclosures of ClientRecords.

Chapter 3 Screening Information.

Form 19 Mental Health Screening Form.

Form 20 Substance Abuse Screening Form.

Form 21 Adaptive Functioning Screening Form.

Form 22 Learning Disability Screening Form.

Form 23 ADHD Screening Form.

Chapter 4 Assessment Forms.


Form 24 Initial Assessment—Adult.

Form 24A Example of Completed Form.

Form 25 Initial Assessment—Children and Adolescents(<18).

Form 25A Example of Completed Form.

Form 26 Personal History—Adult (18+).

Form 26A Example of Completed Form.

Form 27 Personal History—Children and Adolescents(<18).

Form 27A Example of Completed Form.

Form 28 Couple's Information Form.

Form 29 Emotional/Behavioral Assessment.

Form 29A Example of Completed Form.

Form 30 Emotional/Behavioral Update.

Form 30A Example of Completed Form.

Form 31 Diagnostic Assessment Report.

Form 31A Example of Completed Form.

Form 32 Diagnostic Assessment—Lower Functioning.

Form 32A Example of Completed Form.

Form 33 Biopsychosocial Report.

Form 33A Example of Completed Form.

Chapter 5 Psychological Evaluations.


Form 34 Psychological Evaluation—Adult .

Form 34A Example of Completed Form.

Form 35 Psychological Evaluation—Children andAdolescents.

Form 35A Example of Completed Form.

Form 36 Psychological/Vocational Assessment.

Form 37 Neuropsychometric Consultation.

Chapter 6 Treatment Planning Forms and Procedures.


Form 38 Individual Treatment Plan.

Form 38A Example of a Poor Treatment Plan.

Form 38B Example of Completed Form—Adult.

Form 38C Example of Completed Form—Children andAdolescents.

Form 39 Short-Term Therapy Treatment Plan.

Form 39A Example of Completed Form.

Form 40 Treatment Review.

Form 40A Example of Completed form.

Form 41 Treatment Update.

Form 41A Example of Completed Form.

Chapter 7 Progress Notes.


Form 42 Progress Notes.

Form 42A Example of Poor Progress Notes.

Form 42B Example of Completed Form—Adult.

Form 42C Example of Competed Form—Children andAdolescents.

Form 43 Progress Notes—Outline.

Form 43A Example of Completed Form.

Form 44 Group Therapy Progress Notes.

Form 44A Example of Completed Form.

Form 45 Psychiatric Medication Management Progress Notes.

Chapter 8 Other Forms Used during the Course ofTreatment.


Form 46 Referral for Mental Health Services.

Form 47 Informed Consent for Medication.

Form 48 Suicide Contract.

Form 49 Cooperating in Child Rearing.

Form 50 Couple's Analysis of Target Behaviors.

Form 50A Example of Completed Form.

Form 51 Third-Party Prior Authorization Request for ContinuedServices.

Form 51A Example of Poor Authorization Request.

Form 51B Example of Completed Form.

Chapter 9 Chart Review and Outcomes Documentation.


Form 52 Chart Review.

Form 53 Utilization Review Committee Guide to Review Charts forAudit.

Form 54 Utilization Review Committee—Chart ReviewSummary.

Form 55 Medical Records Audit Chart.

Form 56 Statement of Confidentiality for Those Auditing orReviewing Client Charts.

Form 57 Outcome Survey for Adults.

Form 58 Outcome Survey for Children.

Form 59 Outcome Survey for Families and Relationship.

Chapter 10 Termination and Aftercare.


Form 60 Discharge Summary.

Form 60A Example of Completed Form.

Form 61 Termination Letter.

Bibliography and Suggested Readings.

CD-ROM Table of Contents.

About the CD-ROM. 

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