Required Clinical Documents

Overview of required clinical documents for each new client

Required Clinical Documentation For New Clients

• Signed Informed Consent

  • Document Name: Lartey Wellness Welcome Letter, Consent Form & HIPAA Documents

  • Admin team ensures the document is signed before scheduling an intake session

• Intake Note

• Treatment Plan

  • Upload to the client portal, review, and sign by the client

  • Include two goals and two objectives for each goal

• Interpretive Summary [Case Conceptualization]

  • Saved as Psychotherapy Note

  • Length: 8-10 sentences

• Transition Plan

  • Upload document as: LWG Transition Plan Form

• Progress Note

  • Completed for every therapy & med management session within 24 hours

  • Length: 8-10 sentences

• Termination Note

  • Completed for clients who are being terminated or transferred to another clinician within LWG