Forms for the Therapist

Front Cover

Forms for the Therapist

Copyright Page

Contents

List of Icons

List of Forms by Type

Contributors

About the Editor

Preface

Acknowledgments

Part I: Starting and Managing Your Clinical Practice

Chapter 1 FORMS FOR SETTING UP AND DEFINING YOUR PRACTICE

Example Professional Resume (Web Version)

Professional Practice Profile

Vision Implementation Planner

Strategic Planning Worksheet

Professional Will and Instructions

Codicil to Personal or Professional Will

Professional Profile Documents Needed

Business Development and Professional Relationships

Making a Business Plan

Intentional Strategic Planning

Mission Statement

Office Set Up and Marketing Needs

Letter of Introduction to the Community

The 14 Ps of Marketing a Practice, Program or Service

Marketing by Mail (1)

Marketing by Mail (2)

Marketing Your Practice: A Trial Exercise

Free Use of the Media

Sample Letter for a Proposed Community Workshop

Going Green in the Office

Program Development

Models and Procedures for Program Planning

A SWOT Analysis of the Practice

Chapter 2 FORMS RELATED TO FEES

Structuring Payment Plans for Patients Who Cannot Afford Standard Fees

Office Financial Policy

Cancellation and Missed Appointments Notice

Notice of Missed Appointments

Actions to Take When Patients Miss Appointments

Payment Agreement for Past Service Rendered

Past Due Letter Requesting Payment

Doctor's Lien and Authorization of Payment

Office Daily Billing Sheet

Fee Agreement for Psychological Expert Witness Services

Fee Schedule for Clinical Services

Fee Schedule for Medical/Legal Services

Insurance Authorization Log

Insurance Direct Payment Authorization

Chapter 3 HIPAA/PATIENT PRIVACY FORMS

HIPAA Office Staff Guidelines

HIPAA Complaint and Resolution Form

Authorization for Release or Exchange of Information

Permission to Allow Information from a Session to be Used for Research, Teaching, Lecturing, and/or Publication Purposes

Patient Records Access Form

Request for No Records to be Kept

Limits on Patient Confidentiality

Guidelines for the Release of Psychological Test Data

Medicare Advance Beneficiary Notice

Chapter 4 GENERAL INFORMATIONAL HANDOUTS FOR PATIENTS

Welcome Brochure

Employee Assistance Program

Shall I Sign Up with an EAP?

Disclosure of Risks and Benefits Regarding the Use of Psychotherapeutic Medications

10 Steps to a Healthier Brain

Alternative Medicine: Guidelines

Advice for Patients Seeking Services on the Internet

Personal Bill of Rights

Patient Bill of Rights

Chapter 5 FORMS RELATED TO REFERRAL AND CONSULTING SERVICES

Contract for Consulting Services: Brief Form

Consulting Services Agreement with Other Professionals

Memo of Understanding for Professional Services

Agreement for Psychological Expert Witness Services

Confidential Referral

Expert Witness Guidelines

Contracting with Managed Care Companies

Forensic Psychological Assessment Consent

Ethical Guidelines in Interdisciplinary Care

Guidelines for Medication Referrals

Networking to Tap the Hidden Job Market

Chapter 6 FITNESS FOR DUTY AND WORKERS' COMPENSATION FORMS

Notice of Unfitness for Duty

Notice of Return to Duty

Workers' Compensation Information Intake Form

Workers' Compensation Lien Cover Letter

Chapter 7 FORMS RELATED TO PATIENT SERVICES

"Welcome to the Office" Patient Sign In

Psychotherapy Information Disclosure Statement and Consent to Treatment

Patient Confidential Information Form

Confidential Alternate Communications Request

Documenting All Services Rendered

Behavioral Therapy Plan

Needs Appraisal and Services Plan

Review of Behavioral Medication by Physician

Monitoring of Antecedent Events to Self-Defeating Behavior

Components of a Patient's Chart: A Checklist

Evaluation of Therapist

Patient Satisfaction Questionnaire

Patient Satisfaction: Therapy's Greatest Public Relations Approach

Waiting Room Assignment

Jury Duty Excuse

Chapter 8 FORMS RELATED TO THERAPIST'S PROFESSIONAL ACTIVITIES

Continuing Education Log

Weekly Travel Expense Sheet

Expense Account

Supervision Documentation Form

Chapter 9 MANAGING AN OFFICE STAFF

Program Staff Meeting Minutes

Therapist's Evaluation of the Office Staff

Annual Survey of Office Staff

Peer Evaluation of Employee

Employee Self-Evaluation Form

Employer Feedback to Employee from Annual Review

Employee Progressive Discipline

Annual Employee Satisfaction Survey

Unusual Incident Report Form

Request for Time Off

Request for Early Dismissal or Overtime Authorization

Employee Exit Interview

Authorization to Release Employment Information

Authorization for Letter of Reference

Recognizing Early Warning Signals of a Dangerous Employee

Professional Staff Meeting Agenda

Emergency Action Needed: "INA"

When Depression Comes to the Office

Leadership in Today's World

Leadership in the Workplace

Leadership in Large Corporate and Professional Organizations

Facing a Key Crisis in a Business

Chapter 10 TERMINATION OF TREATMENT/PRACTICE FORMS

Release from Responsibility for Discharge

Letter to Terminate Services to a Patient

Professional Practice for Sale and Profile

Practice for Sale – Advertisement

Chapter 11 FORMS FOR SESSION NOTES

Session Notes: Version 1

Session Notes: Version 2

Session Notes: Version 3

Session Notes: Version 4

Relaxation Training and Biofeedback Therapy Session Notes

Group Therapy Notes

Chapter 12 CLINICAL ERRORS, BAD HABITS, ETHICAL COMPLAINTS, AND LAW SUITS

12 Steps for Reducing Your Risks in a Malpractice Suit

Four Issues to be Addressed in Determining Negligence in a Civil Law Suit

Ways to Respond to a Complaint

Managing Clinical Errors, Mistakes, and Mishaps

Bad Habits to Avoid as a Therapist

Medication Consultation by Psychologist

Chapter 13 EXPANDING YOUR PRACTICE

Informed Consent Procedures for Telemedicine

Therapist's Guidelines for Conflict Resolution

Internet-Based Therapy: Is It for Me?

Telephonic Counseling: Is It for Me?

Coaching Managers and Executives

Executive Coaching to Accelerate Learning

Estate and Health Care Planning with Patients

Part II: Intake Forms and Initial Assessment Tools for Evaluating Patients

Chapter 14 ORGANIZING YOUR CHARTS AND EVALUATIONS

Outline for a Comprehensive Clinical Evaluation

Components of a Clinical Chart

Outline for a Standard Clinical Evaluation and Summary Report

Chapter 15 GENERAL ASSESSMENTS: INTAKE, BRIEF, COMPREHENSIVE, AND MORE

Getting to Know You

The Intake Process – Issues to Assess

Legal Intake Form

Intake Assessment and Proposed Treatment Plan

Areas for Exploration for a Comprehensive Mental Health Assessment

Brief Assessment and Diagnostic Summary

Brief Diagnostic Structured Clinical Interview

Sentence Completion-Work

Psychopathy Checklist

Critical Events Time Line

Chapter 16 ASSESSMENTS RELATED TO SPECIFIC TESTS AND SCALES

Practical Model for Interpreting MCMI-III Test Results

Global Assessment of Relational Functioning (GARF) Scale

GAF Evaluation

Social and Occupational Functioning Assessment (SOFA) Scale

Chapter 17 ASSESSMENTS RELATED TO RISK, COMPETENCY, HEALTH, AND NEUROPSYCHOLOGY

Competency to Stand Trial Status Exam

Assessing Lifestyle and Health

Informal Diagnostic Exercises of Aphasia

Neuropsychological Assessment: Patient Information

Part III: Forms, Exercises, and Information for Treating Specific Disorders

Chapter 18 ANXIETY AND STRESS RELIEF WITH RELAXATION ASSESSMENT AND EXERCISES

16 Warning Signs of Post-Traumatic Stress

Personal Stress Management Profile

Progressive Relaxation

Instructions for Focused Breathing

Stressful Life Events

Well-Being Scale

How Well Do You Cope with Life's Circumstances?

Fear and Its Management

The Management of Stress, Anxiety, and Pain

Emotional Fitness

Advice from a Friend

Stress Is Not a Stocking Stuffer

Identifying Traumatic Stress

What Management Can Do to Minimize Employee Stress

Chapter 19 DEPRESSION AND SELF-ESTEEM

Depression Myths

Triple-Column Technique to Understand and Change My Depression

Bipolar: How to be Self-Defeating

Bipolar Disorder Hypersexuality

Feeling Overwhelmed and Desperate

The Happiness Factor

Understanding Seasonal Affective Disorder

Pursuing Peace in the Midst of a Loss

The Self-Esteem Review

10 Self-Esteem Boosters

Chapter 20 INSOMNIA AND SLEEP THERAPY

10 Tips for Better Sleep

Insomnia: What Is It and What Do We Do About It?

Sleep Improvement Program

My Sleep Diary

My Sleep Chart

Sleeping Improvement Log

Helping Sleep Through Use of Medication

Importance of Good Sleep Habits

Chapter 21 ADDICTIVE BEHAVIOR

Signs of Alcoholism

Alcohol Addiction Questionnaire

Alcohol Involvement Scale

Am I Abusing Alcohol and At Risk?

Guidelines for Moderate Drinking

Screen for Gambling Addiction

Do I Have a Gambling Problem?

My Gambling Pattern in the Past Year

Gamblers Anonymous – 20 Questions

Caffeine Consumption Questionnaire

Reasons to Quit Smoking

Chapter 22 SUICIDAL BEHAVIOR

The Intervention Perspective of Suicide

Dangerousness: Warning Factors

No Harm Agreement

Chapter 23 PAIN MANAGEMENT AND COPING WITH MEDICAL DISORDERS

Headaches

Treatment of Chronic Pain

Assessment of Chronic Pain

Charting Perceived Pain

Physical Disorders Associated with Psychological Distress

Patient Report of Illnesses and Medical Problems

Psychological Factors Affecting Physical Condition

Dizziness Questionnaire

Medications Being Taken by Patient

Gastroesophageal Reflux Disease (GERD)

Parkinson's Disease

Chapter 24 ANGER AND VIOLENT BEHAVIOR

How to Handle Angry People

Anger and How to Deal With It

Hostility Discomfort Scale

Behavioral Anger Scale

Anger Inventory

Behavioral Hostility Checklist

My Anger Story

My Diagnostic Anger Map

Five Steps of Anger Control

Dangerous Propensities of a Minor

Risk for Re-offending as a Sex Offender

Part IV: Skill Building Strategies and Tools for Personal Growth and Life Improvement

Chapter 25 STRATEGIES AND TOOLS FOR PERSONAL GROWTH AND HEALTH AWARENESS

My Developmental Experiences of Personal Growth and Development

My Self-Analysis

Considerations in Self-Image Building

My Friendship Circle

My Life's Journey of Growth Experiences

Learning to Live a Life of Mastery

Mastering Motivational Living

My Daily Journal

Test of Personal Meaning

The Interactive Cognitive Model of Emotional Intelligence

Happiness and Optimism Exercises

Good Habits for Healthy Living

Components of Brain Functioning

Journal Writing

Chapter 26 COMMUNICATION TIPS AND EXERCISES

Communication Tips from the Tennis Court

What Kind of Listener Am I?

Communication Exercises in the Perception of Feelings

Model of Communication Patterns

Styles of Communication

The Listening Skills Ladder

The Stings and Thorns of Communication

Nonverbal Communication Checklist

Assertiveness Inventory

Chapter 27 EATING AND EXERCISE LOGS

Personal Exercise Record

Weekly Home Exercise Program

Eating Behavior Schedule

Helping Patients Live an Active Lifestyle

Tips to Manage Weight Loss

Chapter 28 CULTURAL DIVERSITY APPRECIATION EXERCISES

Movies and Videos Focusing on Diverse Populations

Personal Identity Profile

The Cultural Genogram

Chapter 29 CONFLICT RESOLUTION AND PROBLEM SOLVING

Walking around the Edges of Conflict

The Five Steps to Problem Solving

Conflict Resolution and Problem Solving

Problem Solving Diagram

The Problem Solving Worksheet

Problem Solving and Changing Violent Behavior Patterns

Chapter 30 THINKING DISTORTIONS: INFORMATION AND PATIENT EXERCISES

The Bane of Perfectionism: An Obsessive Compulsive Disorder

Thinking Distortions

Chapter 31 BEHAVIORAL MONITORING LOGS

Behavior Monitoring Graph

Monitoring of Antecedent Diagnostic Events to Self-Defeating Behavior

A Look at My Self-Defeating Behavior Pattern

Behavioral Management Program in the Home

Behavioral Observations Chart for Daycare and Hospital Patients

Chapter 32 DEALING WITH CRISIS

How Best to Respond to a Crisis

Crisis Intervention

Facing and Overcoming a Crisis

Trauma Response

The Therapist's Exposure to and the Management of Trauma

Part V: Dealing with Specific Types of Patient Problems and Issues

Chapter 33 SERVING CHILDREN AND THEIR FAMILIES

A. The Family Needs Help to Change

B. Functional and Dysfunctional Families

C. Family Based Assessment

D. Learning Disabilities

E. Attention Deficit-Hyperactivity Disorder (ADD/ADHD)

F. School Performance and Teacher Feedback

G. Communication with Children

H. Exercises for Therapists to Get Children to Communicate

I. Drug Use and Eating Disorders

J. Custody/Visitations

K. New Drivers

L. Other Parenting Management Strategies

Chapter 34 DEALING WITH GERIATRIC PATIENTS

A. Assessment Scales and Checklists

B. Successful Aging

C. Dementia and Alzheimer's Disease

D. Caregivers and Caregiving

Chapter 35 COUPLES THERAPY AND RELATIONSHIP ASSESSMENT AND EXERCISES

A "Perfect" Marriage Wish List

Marital Happiness Scale

Request for Marital Behavior Change

Marital Satisfaction List

Seven Components to Loving

Couples Communication

20 Diagnostic Factors that Indicate Relationship Anger

I Love You and Want You to Know It

Marital Pointers

Marital Problem Area Questionnaire

Pre-Marital Questionnaire

The Scope of Intimacy in Marriage

Navigating the Confrontations of a Discovered Affair

The Pathway to Reconciliation

Marital Action Steps for the Long Run

Interpersonal Relationship Distinctions

Violence in the Home: Partner Violence and What Can Be Done About It

How to Predict a Potentially Violent Relationship

Why Victims of Domestic Violence Struggle with Leaving

Appendix 1: Form Development and Usage for a Clinical Purpose

Appendix 2: Professional Issues in Clinical Practice

Index

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