Therapy Notes 
Dotting the I’s and Crossing the T’s: Getting Your Documents in Place
Aside from scheduling an appointment and checking insurance benefits, what is the number one thing you need to do before you sit with your new client? Paperwork.
Think about all the paperwork a new client completes: demographic form, brief history, consent for treatment, receipt of your practice statement, consent to bill insurance, receipt of your notice of privacy practices. Depending on your type of practice the list could go on.
When someone is going to see you face-to-face, you might house those documents on your website where they can download them and bring them for the first visit. You might mail them or fax them. Or more likely, they will complete them upon their arrival.
But what do you do for a client you are going to see online? A client who may be 4 hours away from you? Or one who is homebound?
Getting the paperwork done and returned to you in an expedient and secure manner is one of the biggest challenges of online therapy. So just how can you do that in a way that maintains security and is efficient? Well, that depends on you and the tools you choose.
Time Is of the Essence
You would not see a face-to-face client without having the appropriate consent forms signed. To do so would place you in a highly vulnerable position both legally and ethically.
Best practice is to be sure all of your required consents and documents are completed BEFORE you conduct a therapy session.
Full Informed Consent
Just as you obtain consent for treatment from your face-to-face clients, you also need to obtain this consent from your online clients.
One of the often overlooked items when starting to see clients online is updating consents and documents to reflect the provision of online services. Because you are conducting therapy in a virtual environment, you need to make sure that your informed consents, declaration of practices or other documents clearly state that. You also want to be sure there is information regarding the risks specific to online therapy. Depending on your particular type of practice, those risks may be significantly different from those of face-to-face therapy.
Getting It Inked
Once all of your documents are in place, how do you get them to your new client?
- Snail Mail – if you have the luxury of time and don’t have an electronic option, you can mail them. You run the risk of mail delays, clients not checking mail daily or simply forgetting. The bigger dilemma is how do they get the forms back to you securely and timely? “It’s in the mail” won’t fly when it’s time for the session and you have no consent on file.
- Email – Email is fine for sending forms. The dilemma, like snail mail, is how do the clients get signed consents back to you quickly and securely? Your clients may not have access to scanners or document signing software. Then there is the issue of email security. You are asking your clients to send private information electronically via email that may not be as secure as you think. A breach could cost you dearly and violate your client’s privacy rights.
- Electronic Document Signing – these services are available and generally considered secure. They are generally not free to use. The downside is that these are stand-alone services so they will not be integrated into your current EHR or therapy platform. You generally have to manually upload them if your platform even offers document sharing. If not, then what?
- Integrated Therapy Platform – Ideally, you want a therapy platform that is capable of fully integrating the documents you share with your client so that you have full access to them and they are all in one place. TheraPlatform has the capability of sharing and storing the documents you use with your clients. You don’t have the hassle of juggling different programs. You don’t have the worries about security and privacy. It’s all in one place. Easier for your client. Functional for you.
As with any service or process you are considering, it’s always a good idea to check with your particular licensing board to be sure you are in compliance with your particular regulatory and licensing requirements. Telehealth for mental health is still quite new in some areas and approved processes and requirements are still evolving.
As always, do your homework and choose wisely. Choosing tools that are designed specifically for the unique needs of therapists optimizes your productivity and increases the chances that you are doing all you can to keep your client’s information secure.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
Free video classes
- Free mini video lessons to enhance your private practice
- 9 Admin tasks to automate in your private practice
Disclaimer: This information does not serve as legal or tax advice. It is only for informational purposes and should serve as a guide to assist you as you work through the decision-making process. You should consult with an attorney and tax advisor for legal and tax advice.