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Tables of Contents for The Paper Office
Chapter/Section Title
Page #
Page Count
Introduction
1
1
Ways This Book Can Help You
1
1
What This Book Contains
2
1
Unique Features
3
1
How to Use This Book In Your Practice
3
1
Quick Start: Recommended Basic Materials
4
1
Availability of Materials on CD-ROM
5
1
A Cautionary Note and Disclaimer
5
1
About Reproducing Materials in This Book
6
1
Continuing Education Credits
6
1
Your Forms and Other Contributions: A Nice Offer
7
1
Future Developments
8
1
Basic Paperwork and Communication Tools
9
19
Basic Paperwork Tools: An Overview
9
1
Presenting Yourself on Paper
10
6
Ethical Aspects of Self-Presentation
10
1
Guidelines for Clear and Accurate Self-Presentations
11
1
The Name of Your Practice
12
1
Your Stationery and Cards
12
3
Your Resume and Curriculum Vitae
15
2
Sample curriculum vitae, partially filled in
17
Your Appointment Book
16
2
What an Appointment Book Should Include
18
1
Computerized Datebooks and Schedulers
18
1
Basics of Record Keeping
18
7
Why Keep Records?
19
1
What Should Be in the Records?
20
1
The Physical Structure for Organizing Your Case Records
21
1
Checklist for client records
22
3
Record Security
25
1
Retention of Records
25
3
How Long Should Records Be Kept?
26
1
Suggestions on Retaining Records
26
1
Preserving Records When You Retire or Die
27
1
Disposal of Your Records
27
1
Financial Tools and Procedures
28
30
Setting Financial Policies for Your Practice
28
5
About Fees
29
1
Ethical Guidelines on Fees
30
1
Setting Your Fee
31
1
Discussing Fees
32
1
Tips on Collecting Fees
33
1
The Income Record
33
1
Sample income record
34
1
The Expense Record I: Your Checkbook
34
2
Choosing a Checking Account
35
1
Guidelines for a Business Checkbook
35
1
Choosing a Credit Card
36
1
The Expense Record II: Monthly/Quarterly Expense Summary
36
2
Monthly/quarterly expense summary
37
1
Methods of Billing
38
9
Credit Cards
38
1
Statements
38
1
Statement Cards
38
1
SuperΨbills
38
1
Computerized Billing Programs
39
1
Billing Services
39
1
Itemized Billing: A Detailed Example
39
1
A Weekly Summary for Billing
39
1
Itemized billing: A detailed example
40
1
A Record of Services Provided
41
1
Weekly summary for billing
42
1
Record of Services provided
43
1
The Patient Account Ledger Billing Form
44
2
Patient account ledger (PAL)
46
1
Collecting Overdue Fees from Clients
47
5
Calling the Client
47
1
A tickler card
48
1
The Tickler File
49
1
Sending a Note on the Bill
49
1
Sending Collection Letters
50
1
Other Methods
51
1
Billing Third Parties--and Getting Reimbursed
52
6
Advice on Procedures for Clients with health Insurance
52
1
What You Need to Know for Insurance Processing
53
1
Billing for Medicare Patients
54
1
Checklist for Avoiding Illegal and Unethical Billing Procedures
55
1
Late Payments from Insurers
56
2
Reducing Malpractice Risk by Operating Ethically
58
59
Ethics and Malpractice
58
4
Why Are Ethical and Legal Issues So Complicated?
58
1
The Major Malpractice Risks for Clinicians
59
1
Table 1. Major Causes of Successful Malpractice Suits against Psychologists
60
1
Four Steps toward Ethical Self-Protection
61
1
Legal Aspects of Malpractice
62
4
When Do Patients Sue?
62
1
What Is Malpractice?
62
1
The Good News (for Us): The Real Risks Are Small
63
1
The Bad News (for Us): Malpractice Accusations Hurt
63
1
What to Do If You Are Complained Against: A Checklist
64
2
Ways to Reduce Your Risk of Malpractice
66
7
Twenty-Three Steps for Risk Reduction
66
5
Other Risk Areas for Malpractice
71
1
Risks in Repressed-Memory Therapy
71
2
Evaluating the Ethicality of Proposed Treatments
73
1
Table 2. Checklist for the Ethicality of Proposed Treatments
74
Avoiding Malpractice in Psychological Testing
73
4
Require the Client to Give Consent
73
2
Know the Rules
75
1
Stay within Your Areas of Competence
75
1
Administer Tests the Way They Were Designed
75
1
Interpret and Report Your Findings Carefully
76
1
Be Alert for Biasing Factors
76
1
Be Aware of Forensic Issues
77
1
Be Thorough
77
1
Boundary Issues
77
1
Dual Relationships
78
7
What Are Dual Relationships?
78
1
Why Avoid Dual Relationships?
78
1
Are you in trouble with a client?
79
2
Types of Dual Relationships
81
1
When Dual Relationships are Not Avoidable: Weighing Their Effect
82
1
Preventing Trouble
83
1
Patient handout on limits of the therapy relationship
84
1
Sexual Intimacies in Therapy
85
14
What Is Meant by ``Sexual Intimacies''?
85
1
With Whom Are Sexual Intimacies Prohibited?
86
1
Who Is Prohibited from Engaging in Intimacies?
86
1
The Damage to the Client and to Therapy
86
1
Negative Consequences to the Clinician
87
1
Not Me! I Would Never!
88
1
Is Sexual Intimacy with a Client Ever Acceptable?
89
2
A Checklist of Preventive Measures
91
1
What to Do If a Client Asks You for Sex
91
1
Consciousness Raising
92
1
What to Do If You Are Attracted to a Client
93
1
Reporting Another Therapist
94
1
Client-Therapist Intimacy: Appropriate and Inappropriate Conduct
94
2
Patient handout on client-therapist contact
96
3
The Duty to Protect (and Warn)
99
3
The Legal Basis
99
1
When Do You Have a ``Duty to Warn''?
99
1
What to Do When You Decide to ``Warn''
100
1
Suicide
101
1
Family Violence and Abuse
102
1
Assessing a Client's Dangerousness to Self and Others
102
10
Prepare Ahead of Time
103
1
Gather Information to Assess Risk
103
1
Evaluate the Risk Factors Present
103
3
Checklist of suicide risk factors
106
3
Analyze the Information Gathered
109
1
Document the Situation and Your Actions
109
1
Manage the Risk by Altering the Therapy
110
1
Do Damage Control
111
1
Limit Your Personal Vulnerability to Violence
111
1
Ethical and Legal Issues in Working with Managed Care Organizations
112
5
Consent Issues
113
1
Confidentiality Issues
113
1
Treatment Issues
114
1
Informing Clients about Managed Care
115
2
Patient handout for informed consent to managed care
117
1
Getting Informed Consent
117
68
The What and Why of Getting Informed Consent
117
7
What Informed Consent Requires
117
5
The Three Steps in Obtaining Informed Consent
122
1
Do Written Consent Forms Have a Negative Effect on Clients or Treatment?
123
1
The Five Paths to Informed Consent
124
1
The First Path to Informed Consent: The Client Information Brochure
124
23
Kinds of Brochures
124
1
Types and Purposes of Brochures Used in Psychotherapy
125
1
How to Use the Model Client Information Brochure
125
2
The Model Client Information Brochure
127
20
The Second Path to Informed Consent: The Question List as a Guide to Discussion
147
7
Question list for therapist-client discussion (client's version)
152
2
The Third Path to Informed Consent: Lists of Clients' Rights
154
4
About Handouts 5, 6, and 7
154
1
First clients' rights form (The Rights of Clients)
155
1
Second client's rights form (Clients' Rights in Therapy)
156
1
Third clients' rights form (Client Bill of Rights)
157
1
The Fourth Path to Informed Consent: Psychotherapy Contracts
158
15
The Nature of Contracts
158
1
A Checklist for a Psychotherapy Contract: Elements and Options
159
3
A Contract for Individual Therapy with an Adult
162
1
Contract for individual adult therapy
163
1
About Contracts for Couples and Families
164
1
Contracts for Therapy with Minors
165
1
Contract with parent/guardian for psychotherapy with a minor
166
2
Contract for psychotherapy with an older child or adolescent
168
1
A Contract for Group Therapy
169
2
Contract for group therapy
171
2
The Fifth Path to Informed Consent: Consent to Treatment and Other Services
173
12
Generic Consent to an Adult's Treatment
173
1
Generic Consent to a Minor Child's Treatment
173
1
Form for generic consent to treatment of an adult
174
1
Form for generic consent to treatment of a child
175
1
Consent to Counseling for a Child of Divorce
176
1
Authorization to Record Sessions and Use Case Materials
177
1
Agreement for parents regarding limitations and goal of psychotherapy with a child of divorce
178
2
Release/permission form for recording sessions and using case materials in research, teaching, and professional publishing
180
2
Consent to Psychological Testing
182
1
Consent to Being Evaluated for a Third Party
182
1
Consent form and contract for psychological testing and evaluation
183
1
Form for consent to being evaluated for a third party
184
1
Intake and Assessment Forms and Procedures
185
64
Creating the Client's Chart
185
2
The Chronology of Record Keeping
185
1
The Contents of the Record
186
1
Phase 1: The Initial Telephone Contact
187
5
Reasons for Refusing a Caller as a Client
188
1
Getting the Essential Data
188
3
First-contact record
191
1
Phase 2: The Preappointment Package and Other Types of Preappointment Contact
192
6
Ways to Respond before the Initial Appointment
192
1
Appointment card or slip
193
1
Letter of appointment confirmation
194
1
Ways of Dealing with No-Shows and Early Dropouts
195
1
Letter to a second-time no-show for an initial appointment
196
2
Phase 3: The New Client's Arrival for a First Meeting
198
34
Ways of Collecting Further Client Information
198
2
Obtaining Client Demographic Information
200
1
Client demographic information form
201
3
Obtaining Client Clinical Information
204
1
Client clinical information form
205
4
Obtaining Client Medical Information
209
2
Brief health information form
211
3
Assessing Chemical Use
214
1
Chemical use survey
215
2
Obtaining Financial Information
217
1
Financial information form
218
3
Assuring Financial Responsibility
221
1
Agreement to pay for professional services
222
1
Problem Checklists
223
1
Adult checklist of concerns
224
2
Child checklist of characteristics
226
2
Obtaining Developmental Information
228
1
Child developmental history record
229
3
Phase 4: First Meeting with a New Client
232
7
Using the Intake Interview Questions and Guide
233
1
Special Considerations for Interviewing a Child
233
1
The Evaluation of Mental Status
234
1
Intake interview questions and guide
235
2
Mental status evaluation report
237
2
Phase 5: Summarizing the Intake Information
239
10
Summarizing Chemical Use and Suicide Risk Data
239
1
Formulating the Whole Case
239
1
Chemical user's case formulation
240
2
Suicide risk assessment summary and recommendations
242
2
Intake summary and case formulation
244
5
Planning and Then Documenting Treatment
249
43
Treatment Planning
249
16
Issues
249
1
Guidelines for Treatment Planning
250
1
Systems and Formats of Treatment Planning
251
3
Other Points in Planning Treatment
254
2
Formulating Treatment Plans for Managed Care Organizations
256
2
Individualized treatment plan for managed care organizations
258
7
Documenting Treatment's Progress
265
19
Note Taking: Guidelines and Suggestions
265
7
The Problem-Oriented Record
272
2
Problem list for a problem-oriented record (POR)
274
3
POR progress note form
277
1
Completed sample of a POR progress note form
278
1
Two Structured Progress Note Forms
279
2
Structured progress note form
281
2
Structured progress note form for group therapy
283
1
Client-Generated Records
284
1
Case Termination
284
5
Reasons for Terminating or Transferring a Patient
285
1
How to Terminate Treatment in Different Situations
285
4
The Case Closing Summary
289
3
Outline for Dictation
290
1
A Termination Summary Form
290
1
Termination summary form
291
1
Confidentiality and Releasing Records
292
43
Understanding Confidentiality
292
12
Basic Definitions
292
2
Exceptions to Confidentiality
294
2
Other Points about Confidentiality and Its Limitations
296
1
Confidentiality and Children
297
1
Confidentiality and HIV-Positive Clients
298
1
A Handout on the Limits of Confidentiality
299
2
Patient handout on the limits of confidentiality
301
3
Maintaining Confidentiality
304
3
Guidelines for Maintaining Confidentiality
304
2
Creating Confidential Records
306
1
A Quick Test
307
1
Releasing Clients' Records
307
11
A Pretest
308
1
Ethical Considerations in Releasing Records
308
1
Legal Requirements for a Release of Records
309
1
Eight Variations on the Theme of ``Please Send Your Records''
310
6
Guidelines and Considerations in Sending Records
316
2
Comments on the Pretest
318
1
Forms for Requesting and Releasing Information
318
5
A Briefer Request/Release Form
318
1
Briefer form for requesting/releasing confidential records and information
319
1
A Comprehensive Request/Release Form
320
1
Requesting or releasing confidential records and information
321
2
More Specific Forms for Releasing Information
323
8
A Release-of-Records Form Letter
232
91
Releasing Psychological Test Results
323
1
A release-of-records form letter
324
2
Request/authorization for release of evaluation information
326
1
Releasing Information to an Attorney
327
1
Releasing Records to an Insurance Company or Other Third-Party Payer
327
1
Authorization to release confidential information to an attorney
328
1
Authorization to release confidential information to a health insurer or other third-party payer
329
2
Releasing Information to the Patient's Family
331
1
Authorization to release confidential information to family members
332
Confidentiality When Faxing Records or Sending E-Mail
331
2
Confidentiality Notifications
333
2
APPENDIX: RESOURCES
335
14
A.1. Annotated Bibliographies
335
8
A.1a. Independent Practice
335
1
A.1b. The Law, Ethics, and Malpractice
336
2
A.1c. Sexual Contact with Clients
338
1
A.1d. Practice Guidelines from Professional Organizations
339
1
A.1e. Clinical Records
340
1
A.1f. Managed Care
341
2
A.2 Resources for Therapy with Minorities
343
1
A.3 Suppliers
343
2
A.3a. Mail-Order Suppliers of Office Equipment
343
1
A.3b. Mail-Order Suppliers of Office Forms and Stationery
344
1
A.3c. Miscellaneous
345
1
A.4. Publishers and Distributors of Tests, Clinical Forms, and Other Materials for Practitioners
345
4
REFERENCES
349
12
INDEX
361
4
Feedback Form
365
1
Instructions for Installing the Forms and CE Test onto Your Computer
366