Preface to the Fourth Edition ix
Introduction xi
Chapter 1 Administrative and Intake Forms 1
Introduction
Form 1 Screening Information 6
Form 2 Notice of Appointment 7
Form 3 Consent to Treatment and Recipientâs Rights 8
Form 4 Recipientâs Rights Notification 9
Form 5 Financial Policy 11
Form 6 Payment Contract for Services 12
Form 7 Code of Ethics and Mission Statement 14
Form 8 Therapistâs Ethics Statement 15
Form 9 Agreement Regarding Minors 16
Form 10 Preauthorization for Health Care 18
Form 11 Confidentiality Agreement 19
Chapter 2 Forms Designed for HIPAA Compliance 21
Introduction
Form 12 Privacy of Information Policies 27
Form 13 Request to Amend Health Records 30
Form 14 Request for Restricted Use/Disclosure of Records 31
Form 15 Request for Alternative Means of Confidential Information 32
Form 16 Release of Information Consent 33
Form 17 Record of Requests for Client Information 34
Form 18 Request for Listing of Disclosures of Client Records 35
Chapter 3 Screening Information 37
Form 19 Mental Health Screening Form 38
Form 20 Substance Abuse Screening Form 39
Form 21 Adaptive Functioning Screening Form 40
Form 22 Learning Disability Screening Form 41
Form 23 ADHD Screening Form 42
Chapter 4 Assessment Forms 43
Introduction
Form 24 Initial Assessmentâ"Adult 50
Form 24A Example of Completed Form 58
Form 25 Initial Assessmentâ"Children and Adolescents (<18) 66
Form 25A Example of Completed Form 74
Form 26 Personal Historyâ"Adult (18+) 82
Form 26A Example of Completed Form 90
Form 27 Personal Historyâ"Children and Adolescents (<18) 98
Form 27A Example of Completed Form 106
Form 28 Coupleâs Information Form 114
Form 29 Emotional/Behavioral Assessment 120
Form 29A Example of Completed Form 124
Form 30 Emotional/Behavioral Update 128
Form 30A Example of Completed Form 129
Form 31 Diagnostic Assessment Report 130
Form 31A Example of Completed Form 136
Form 32 Diagnostic Assessmentâ"Lower Functioning 141
Form 32A Example of Completed Form 145
Form 33 Biopsychosocial Report 149
Form 33A Example of Completed Form 152
Chapter 5 Psychological Evaluations 155
Introduction
Form 34 Psychological Evaluationâ"Adult 157
Form 34A Example of Completed Form 171
Form 35 Psychological Evaluationâ"Children and Adolescents 186
Form 35A Example of Completed Form 200
Form 36 Psychological/Vocational Assessment 214
Form 37 Neuropsychometric Consultation 224
Chapter 6 Treatment Planning Forms and Procedures 231
Introduction
Form 38 Individual Treatment Plan 236
Form 38A Example of a Poor Treatment Plan 237
Form 38B Example of Completed Formâ"Adult 238
Form 38C Example of Completed Formâ"Children and Adolescents 240
Form 39 Short-Term Therapy Treatment Plan 242
Form 39A Example of Completed Form 243
Form 40 Treatment Review 245
Form 40A Example of Completed form 247
Form 41 Treatment Update 249
Form 41A Example of Completed Form 250
Chapter 7 Progress Notes 251
Introduction
Form 42 Progress Notes 258
Form 42A Example of Poor Progress Notes 259
Form 42B Example of Completed Formâ"Adult 260
Form 42C Example of Competed Formâ"Children and Adolescents 261
Form 43 Progress Notesâ"Outline 262
Form 43A Example of Completed Form 263
Form 44 Group Therapy Progress Notes 264
Form 44A Example of Completed Form 265
Form 45 Psychiatric Medication Management Progress Notes 266
Chapter 8 Other Forms Used during the Course of Treatment 269
Introduction
Form 46 Referral for Mental Health Services 272
Form 47 Informed Consent for Medication 273
Form 48 Suicide Contract 274
Form 49 Cooperating in Child Rearing 275
Form 50 Coupleâs Analysis of Target Behaviors 280
Form 50A Example of Completed Form 282
Form 51 Third-Party Prior Authorization Request for Continued Services 284
Form 51A Example of Poor Authorization Request 285
Form 51B Example of Completed Form 286
Chapter 9 Chart Review and Outcomes Documentation 287
Introduction
Form 52 Chart Review 289
Form 53 Utilization Review Committee Guide to Review Charts for Audit 291
Form 54 Utilization Review Committeeâ"Chart Review Summary 295
Form 55 Medical Records Audit Chart 296
Form 56 Statement of Confidentiality for Those Auditing or Reviewing Client Charts 302
Form 57 Outcome Survey for Adults 303
Form 58 Outcome Survey for Children 304
Form 59 Outcome Survey for Families and Relationship 305
Chapter 10 Termination and Aftercare 307
Introduction
Form 60 Discharge Summary 309
Form 60A Example of Completed Form 311
Form 61 Termination Letter 313
Bibliography and Suggested Readings 315
CD-ROM Table of Contents 317
About the CD-ROM 319
