Policy & Process for Couples Intake Structure
Purpose: To establish a clear, consistent, and clinically sound structure for handling couples intake sessions at Lartey Wellness Group. This policy ensures compliance with documentation and consent standards, promotes equitable assessment of both partners, supports continuity of care, and provides a unified workflow for clinicians, CSRs, and billing staff. 1. General Policy
A. Individual Intakes Are Encouraged (Not Mandatory)
If both partners have insurance, we encourage both partners to complete their own individual intake session before starting couples therapy.
“We encourage both partners to complete a short individual intake session first. This helps each partner share their concerns privately and ensures the therapist has a full understanding of both perspectives.”
If only one partner has active insurance, proceed with the couple’s intake under the insured partner, but:
l Both partners must still complete their own consent forms.
l The therapist will ask questions to both partners equally during the intake.
“If only one partner has insurance, we can still proceed. The intake will be done under the insured partner’s account, but the therapist will ask questions to both partners equally. Both partners will also need to complete their consent forms.”
B. One Couples Therapist Should Complete Both Individual Intakes
Based on therapist feedback:
The assigned couples therapist should conduct both individual intakes.
This ensures continuity, reduces bias, and follows best practices (e.g., Gottman Method).
C. Consent Forms
Regardless of which partner’s insurance is used:
Each partner must sign their own HIPAA and treatment consents.
No partner should have access to the other partner’s private information or individual notes.
2. Couples Intake Session Process
A. During a couples intake session
Therapists should:
l Ask intake and assessment questions equally to both partners.
l Document information for both partners in the notes when clinically relevant.
l The primary chart (the insured partner’s chart) can include relevant details about the partner only if it contributes to treatment, such as:
trauma history
substance use
mental health symptoms that affect the relationship
B. If both partners complete individual intakes
Each intake is documented in their own chart.
Couples therapy notes go under the primary billing chart only, not both.
3. Account & Scheduling Workflow
A. When a couple expresses interest in therapy:
l Create two separate profiles (Partner A and Partner B).
l Collect consents for both.
l Clarify billing:
l Determine whose insurance will be used for couples sessions.
l That partner becomes the “account owner” for couples therapy.
B. Intake Structure
1. Individual intake – Partner A
2. Individual intake – Partner B
3. Joint couples intake session
4. Begin ongoing couples therapy after both individual intakes are completed.
C. Documentation
Individual information stays in each partner’s chart.
Couples notes go into the primary chart based on billing.
4. Summary: Final Workflow
âś” Encourage both partners to complete individual intakes if both are insured.
âś” The same couples therapist should complete both individual intakes.
âś” Both partners must sign their own consent forms.
âś” Intake questions during couples sessions should be directed to both partners equally.
âś” Keep individual information in individual charts; couples notes go in the billing chart.
============================================================== Couples Intake Process Flowchart
Start → Couple Expresses Interest in Therapy
1.Check Insurance
├─ Both partners have insurance → Encourage both to do individual intakes
└─ Only one partner has insurance → Intake is done under insured partner’s chart, therapist asks both partners equally, both complete consent forms
2.Create Client Profiles
├─ Partner A → Profile + HIPAA/consent
└─ Partner B → Profile + HIPAA/consent (if both have insurance)
3.A Individual Intakes
├─ Therapist conducts Partner A intake
└─ Therapist conducts Partner B intake
3.B Joint Couples Intake Session
├─ Therapist asks questions to both partners equally
└─ Notes documented in primary/billing chart, only clinically relevant info from partner in the other chart
4.Begin Ongoing Couples Therapy
├─ Ensure both partners’ consent forms completed
└─ Therapy billed under insured partner’s chart
End
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