As a student therapist, I’ve received a brutal reality check on the volumes of paperwork required in the mental health field. I’m admittedly not a “type-a personality” and can overlook critical details at times. This page is a reference source of information from all prior coursework on the paperwork I’ve encountered during the internship so I don’t miss the “Critical Details”….
While every agency requires a unique set of documents in a client’s file, the following documents are generally required: (1) Client Contact Information; (2) Informed Consentl (3) Biopsychosocial Form; (4) Treatment Plan (5) Progress Note; & (6) Discharge Summary
Initial Assessment Information
The Treatment Plan