The Paperwork…

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

Here is information on a biopsychosocial assessment

Here is information on a mental status exam

Progress Notes

Here is information on a progress note.  

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The Treatment Plan

Here is information on the treatment Plan

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Discharge Summary Sample

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