Sample Intake Note, Interpretive Summary, Transition Plan, etc
Check out this sample of the ideal Intake. Learn more about the Interpretive Summary and Transition Plan. Take a look at the Mental/Behavioral Health diagnoses that are accepted.
The Interpretive Summary/Process Note and the Transition Plan MUST be completed after having completed the Intake Note
Sample Intake Note
For OBJECTIVE CONTENT: Provider reviewed all consents with (client name) and parent (if under 16); policy practices; confidentiality; cancellations and communication between sessions. They were also advised of billing and fee agreements. The client (parent if appropriate) expressed a clear understanding of all documents and had no concerns. The client (parent, if applicable) was also advised that this provider is a mandated reporter and must report any disclosures of abuse or neglect to the appropriate authorities. ***Please make this statement, as written, a staple for EVERY intake.
Additionally, ALWAYS indicate if others are present for the session; under "participants" use the dropbox to add the parent.
Interpretive Summary/Psychotherapy Note
An Interpretive Summary MUST be completed at the time of completing the Intake Note.
An Interpretive Summary is a summarization in narrative form, of the intake assessment and the treatment plan. It should be completed on TherapyNotes as a Psychotherapy Note.
Transition Plan
Transition Plans are required and are to be placed on each client’s file at the completion of the Intake and Treatment Plan. Essentially, this document is a termination note but you will record how the client is expected to achieve their objectives during sessions. This document is workable throughout their entire time the client is with you and you are able to continually edit it to state whether significant changes are being experienced and if they have met their objectives.
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