This concise volume examines exactly what is involved in keeping adequate clinical records of individual, family, couple and group psychotherapy. The authors discuss: limits of confidentiality; retention and disposing of records; documentation of safety issues; client access to records; treatment of minors; and training and supervision issues. Throughout the book, legal cases, vignettes and professional commentary help readers to consider legal and ethical issues.

This book provides an essential framework for understanding record keeping within legal, ethical, supervisory, and clinical contexts. More than a simple reference book, it introduces the concept of using records as therapeutic tools to strengthen the therapeutic relationship and facilitate clinical supervision

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.

CASE DOCUMENTATION IN COUNSELING AND PSYCHOTHERAPY teaches counselors and psychotherapists how to apply counseling theories in real-world settings. Written in a clear, down-to-earth style, the text provides a comprehensive introduction to case documentation using four commonly used clinical forms: case conceptualization, clinical assessment, treatment plan, and progress note. These documents incorporate counseling theory and help new practitioners understand how to use theory in everyday practice. Case studies illustrate how to complete documentation using each of seven counseling models. Readers also learn about the evidence base for each theory as well as applications for specific populations. Designed to produce measurable results that have value beyond the classroom, the text employs learning-centered, outcome-based pedagogy to engage students in an active learning process. Its case documentation assignments-created using national standards-help students apply concepts and develop professional skills early on in their training. When students become practicing mental health professionals they can use this book-with its practical overviews of theories, conceptualization, treatment planning, and documentation-as a clinical reference manual. Important Notice: Media content referenced within the product description or the product text may not be available in the ebook version.

Filling in the gaps from students' lack of experience and confidence, The Beginning Psychotherapist's Companion, Second Edition is a supportive and empathetic guide, addressing real-world concerns and providing essential insights not taught in textbooks. With a reassuring and clear writing style, Willer offers practical suggestions and clinical examples to address the professional development and emotional concerns of the beginning psychotherapist. She guides readers through structuring the first session, making clinical observations, and establishing a therapeutic alliance. Through the use of culturally diverse clinical vignettes, Willer discusses the foundations of ethical practice, including informed consent, confidentiality, documentation, and setting boundaries. The reader is guided on how and when to refer clients for medication and other health care. Crisis management principles are detailed, including suicide and violence risk assessment, child abuse, elder abuse, intimate partner violence, and rape. Willer also provides professional advice on contemporary concerns such as social networking, online searches of clients, the psychotherapist's internet presence, and other important emerging challenges. Comprehensive, practical, and thoroughly updated, The Beginning Psychotherapist's Companion, Second Edition is the ideal resource for students and early career psychotherapists.