Private Practice Forms (English)
Digital Download (Word file).
These files are for private pay practices.
- Intake Assessment (aka Biopsychosocial Assessment) for Individual Adults
- This document is for those in private practice that are looking for an evaluation assessment for their first session. It is comprised of 7 pages with pages, plus 2 pages of the Mental Status Exam (in checklist format), totaling to 9 pages for this file. This document is used during the first appointment, and was created by Counseling and Trauma Family Therapy, Inc. This evaluation does not go in depth with the trauma assessment because it is something we do on an ongoing basis with our clients.
- Informed Consent, & Policies for Self-Pay – Telehealth
- Informed Consent, & Policies for Self-Pay – In-Person Services
- Sliding Scale Agreement is a clause that is included under Payment.
- Informed Consent, Policies & Agreement for Self-Pay for Children & Teens (Minors)
- Notice of Privacy Practices
- Acknowledgment of Receiving Notice of Privacy Practices
- Credit Card Request
- This is a 1-page document ready to be replaced with your practice’s information and has the spaces indicated for your client to write their card information so you hold that on file. I used it only for no-shows/late cancellations.
- Progress Letter
- Two documents are included. One style includes the Objective, Intervention, Assessment, Plan, and the other progress note is for those that want to checkbox their way through the progress note.
- Authorization to Use or Disclose Protected Health Information
- This is a 2-page document outlining information necessary to disclose or release protected client information to a family member, a professional or someone else to help with your client’s case.
- Revocation of Authorization of Release of Info
- This is a 1-page document that can be used as the written consent necessary for the client to withdraw their “Authorization to Use or Disclose Protected Health Information” release.
- Superbill Template
- A 1-page template that has the indicated slots for clinicians to easily input the information that is necessary for a superbill, which is a medical receipt for Out-of-Network benefits.
- Address Change Addendum
- I used this document when clients would change addresses and I needed to update their file. It’s a simple 1-page document.
- Treatment Plan
- A 3-page template covering the basic necessities of a treatment plan for a clinician in private practice. The first page is the initial plan, the second page is a revision treatment plan and includes mental status exam changes, and the third page is also optional and includes questions to answer regarding a client’s long-term goals progress, or short-term goals progress.
- Consultation Call Script- Worried about what to say during your consultation calls? This script includes my screening questions & scenarios of what to say and do when you need to refer out. It is a simple 3 page script. This also includes the flow and language I use to schedule clients and discuss pay.
- Termination Letter
- This document comes with my letterhead as an image with an overlay of a textbox with the template copy, which can all be modified per your client’s reason for termination.
- Phone Log/Referral Log (optional)
- This document comes with a log to track incoming calls, and another log on the other page to track client calls. You can print this page per client to keep in their files and track when they call and their reason for contacting you in between appointments. Eventually, I transitioned away from this document and logged it in my progress notes.
These document have not been revised by an attorney.
All are provided in .doc format so you can make edits. Files expire after 30 days. Please download as soon as you purchase. Product is copyright protected. Once purchased, you may use it for as many of your events as you’d like. Sharing is prohibited. Please honor this.
No refunds on digital products.