Category: Session Documentation

  • Collaborative/Concurrent Documentation (With Examples)

    Collaborative/Concurrent Documentation (With Examples)

    Are you ready to shake things up and transform the mental health field? Imagine a world where mental health practitioners collaborate seamlessly to provide tailored, comprehensive care for each client. With collaborative documentation, this vision is within reach. By pooling your expertise with other professionals, you can unlock invaluable insights and develop innovative treatment plans that genuinely […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • 90853 CPT Code: Complete Description (+Reimbursement Details 2025)

    90853 CPT Code: Complete Description (+Reimbursement Details 2025)

    CPT codes are numbers used to reimburse specific mental health services. CPT codes are essential for billing, ensuring the accuracy of services reported, and receiving reimbursement from third-party payors. Billing the correct CPT code is necessary for a mental health clinician. CPT codes help ensure accurate documentation of the services you provide. Psychotherapists must know […]
    Marissa Moore, LPC, LCPC Avatar
    Marissa Moore, LPC, LCPC
  • How to Properly Identify and Document Impairment in Mental Health?

    How to Properly Identify and Document Impairment in Mental Health?

    As a mental health professional, providing accurate and detailed documentation of a client’s case history and present symptoms is crucial. By thoroughly and ethically reporting on impairments in functioning, you ensure your clients get the coverage and care they need. But how do you accurately and ethically record the client’s impairments to make a case […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • How to Take Effective Psychology Notes: Importance, Techniques & Best Practices

    How to Take Effective Psychology Notes: Importance, Techniques & Best Practices

    A sometimes-overlooked skill, note-taking can significantly impact the quality of mental health professionals’ work. Effective notetaking helps psychologists: This article explores several techniques and best practices for note-taking that are tailored to the specific needs of psychologists. The Importance of Note-taking for Psychologists Psychologists manage vast amounts of information that includes data obtained through clinical […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist
  • How to Write School Counselor Notes? (With School Counseling Notes Template & Forms)

    How to Write School Counselor Notes? (With School Counseling Notes Template & Forms)

    The ABCs of Documentation for School Counselors: Notes, Forms, Templates, and More Welcome to school counseling, where dedicated professionals tirelessly support and guide students on their educational journey. As a school counselor, your role is vital in helping students cope with challenges, develop essential life skills, and navigate through the ups and downs of adolescence. […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • Simplepractice vs Therapynotes: A Detailed Comparison (Features, Cost & Reviews)

    Simplepractice vs Therapynotes: A Detailed Comparison (Features, Cost & Reviews)

    SimplePractice and TherapyNotes are two popular electronic health records (EHR) and practice management platforms that offer several great features for mental health professionals. TherapyNotes delivers simple efficiency, while SimplePractice offers a wealth of premium options. This article explores how each platform differs in features, cost, and value. SimplePractice vs TherapyNotes: How User-Friendly are the Platforms? TherapyNotes is known […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist
  • Mental Health ICD-10 Codes Cheat Sheet

    Mental Health ICD-10 Codes Cheat Sheet

    Attention all mental health professionals! Are you tired of flipping through countless pages and scrolling endlessly through online databases to find the perfect ICD-10 code for your mental health diagnosis? Well, look no further! This comprehensive guide has everything you need to revolutionize how you navigate the world of mental health coding. Whether you're a […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • Informed Consent in Counseling (Benefits, Tips & Examples)

    Informed Consent in Counseling (Benefits, Tips & Examples)

    Have you ever found yourself in a hospital awaiting surgery or sitting in a therapist’s office, only to be handed a consent form before your treatment commenced? In healthcare, it is commonplace for doctors and mental health professionals, including counselors and therapists, to ask clients to provide their informed consent. This crucial step ensures that individuals have been adequately […]
    Dr. Salwa Zeineddine Avatar
    Dr. Salwa Zeineddine
  • Occupational Therapy Documentation – OT Notes (With Examples)

    Occupational Therapy Documentation – OT Notes (With Examples)

    As occupational therapists and healthcare professionals, we know how important thorough documentationis. Not only does it protect us legally, but it allows us to monitor our clients’ progress over time and collaborate with other providers. Among the various notes we write, occupational notes seem to get the least love 🙁 They’re often an afterthought we scribble down between sessions rather than an opportunity to showcase […]
    Dr. Salwa Zeineddine Avatar
    Dr. Salwa Zeineddine
  • SOAP Notes in Mental Health Counseling: Examples, Templates & Writing Guide (2025)

    SOAP Notes in Mental Health Counseling: Examples, Templates & Writing Guide (2025)

    Sometimes, one might have nightmares for no reason at all. At other times, your work might be spilling over into your dreams! You are astonished. Aren’t you? Let me explain: you are a mental health provider struggling with hundreds of patient cases. You scribble down unorganized therapy notes, and you end up crashing with therapeutic standards […]
    Dr. Salwa Zeineddine Avatar
    Dr. Salwa Zeineddine
  • Can Psychotherapy Notes be Subpoenaed?

    Can Psychotherapy Notes be Subpoenaed?

    Receiving a subpoena is not something many mental health clinicians like to deal with. You may feel overwhelmed and scared if you’ve received a subpoena to release information about a client. Many clinicians have questions about what is and isn’t required of you. Subpoenas are tricky to deal with because psychotherapy notes aren’t a part of the […]
    Marissa Moore, LPC, LCPC Avatar
    Marissa Moore, LPC, LCPC
  • How to Write Therapy Notes (With Examples)

    How to Write Therapy Notes (With Examples)

    What Are Therapy Notes and How to Write Them? Your last session ran over time, you are making sure your patient is wearing the broadest smile, feeling supported, and having all his questions answered; tens of patients are still waiting for your consultation; you have a pile of client emails that need an answer, and […]
    Dr. Salwa Zeineddine Avatar
    Dr. Salwa Zeineddine
  • How to Facilitate a Successful Group Therapy Session Online (Platform, Ideas, Tips for therapists)

    How to Facilitate a Successful Group Therapy Session Online (Platform, Ideas, Tips for therapists)

    A significant shift in the field of psychotherapy was the transition from traditional in-person group therapy sessions to online group therapy. Accelerated (and in many cases, required) by the COVID-19 pandemic, online group therapy expanded opportunities for therapists to provide support and treatment to a much larger audience. This article explores how psychotherapists can effectively […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist
  • ICD-10 Code for Suicidal Ideation 2024 – R45.851

    ICD-10 Code for Suicidal Ideation 2024 – R45.851

    Accurate coding is critical for proper billing, record-keeping, and statistical analysis. It is the linchpin that connects various aspects of client care, administrative processes, and research data and analyses. Accurate and appropriate coding is even more critical in the field of mental health, where understanding the client’s condition through precise codes is essential for proper […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist
  • DSM-5 Diagnostic Criteria for ADHD

    DSM-5 Diagnostic Criteria for ADHD

    The Diagnostic and Statistical Manual of Mental Disorders (DSM) has a long history of revisions and is essential to a mental health professional’s work. If you’re a mental health provider, you most likely work from the DSM-5, one of the more recent manual versions. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is […]
    Marissa Moore, LPC, LCPC Avatar
    Marissa Moore, LPC, LCPC
  • How to Write a Psychosocial Assessment (With Examples)

    How to Write a Psychosocial Assessment (With Examples)

    Are you a mental health professional looking to enhance your skills and dive deeper into the world of psychosocial assessments? Look no further! Our exciting guide will take you on a journey to mastering this critical aspect of mental health care. From the differences between psychosocial and biopsychosocial assessments to insights from nursing and social […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • Most Frequently Used Mental Health ICD-10 Codes Used By Therapists (2025 Updated)

    Most Frequently Used Mental Health ICD-10 Codes Used By Therapists (2025 Updated)

    Keeping up with ICD-10 updates can feel like a moving target, especially when you’re already focused on helping clients, managing documentation, and ensuring your notes are audit-ready. This guide breaks down the most frequently used ICD-10 codes for mental health professionals in 2025, explaining key updates, code changes, and how they apply in everyday clinical practice. You’ll also […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • International Classification of Diseases Tenth Revision (ICD-10)

    International Classification of Diseases Tenth Revision (ICD-10)

    If you have recently joined the mental health profession or are seeking an update on a familiar system, you are embarking on a fulfilling and rewarding career path. As you progress, you will realize the significance of staying up-to-date with the International Classification of Diseases, Tenth Revision (ICD-10) 2023 coding system. This system is crucial […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • Supervision Notes Template

    Supervision Notes Template

    As a mental health practitioner, we understand that providing the best possible care for your clients is your top priority. We also recognize that to achieve this, it’s essential to continuously improve your skills and stay up-to-date with the latest best practices. Don’t settle for mediocrity – seek ongoing supervision to take your skills to […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • What is Case Conceptualization & How to Write it (With Examples)

    What is Case Conceptualization & How to Write it (With Examples)

    The Ultimate Guide to Case Conceptualization: Our Top Tips, Outlines, and Real-life Examples As a mental health counselor, case conceptualization is one of the most essential skills you can develop to understand your clients and find the most effective treatment. But for new counselors, the process can be overwhelming. How do you synthesize all the […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • What is a Mental Health Intake Assessment?

    What is a Mental Health Intake Assessment?

    As a mental health professional, the intake assessment is one of the most crucial moments in your work with new clients. During this initial meeting, you can establish trust and rapport, gather information about your client's situation, and set the right tone for your work together. With a well-structured mental health intake assessment, you can […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • Treatment Summary Template for Psychotherapy: Best Practices

    Treatment Summary Template for Psychotherapy: Best Practices

    Do you need help to keep up with creating practical treatment summaries for your clients? We know it’s tough to balance everything while providing exceptional care. But what if we told you you can learn to write stunning summaries quickly? Yes, you heard it right! Our ultimate guide is here to take you on a journey of […]
    Courtney Gardner, MSW Avatar
    Courtney Gardner, MSW
  • What are IGBIRP Notes?

    What are IGBIRP Notes?

    IGBIRP Introduction Within the mental health field, effective documentation and structured treatment planning are essential elements of providing quality care to clients. The IGBIRP Progress Notes Method offers mental health professionals a systematic framework for organizing, documenting, and evaluating client progress. This method assures comprehensive assessment, individualized treatment planning, and ongoing monitoring to support clients in achieving their therapeutic […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist
  • ICD-10 Code for Altered Mental Status Unspecified- R41.82

    ICD-10 Code for Altered Mental Status Unspecified- R41.82

    Introduction "Altered Mental State, Unspecified" is a term used to describe a change in a person's mental function or consciousness that is not specifically identified or diagnosed. This diagnosis indicates there is a noticeable difference or disturbance in typical mental clarity, perception, awareness, cognition, or responsiveness, but the exact cause or specific nature of the […]
    Angela M. Doel, Psychotherapist Avatar
    Angela M. Doel, Psychotherapist