CLIENT NOTES GUIDE - THERAPIST BE READY!

The Intake Documentation Checklist Every Therapist Needs Before Their Next Session WHAT THIS CHECKLIST HELPS YOU REVIEW ✓ Intake paperwork and informed consent ✓ Biopsychosocial history and presenting problem ✓ Treatment history ✓ Mental status exam ✓ Screening tools ✓ Risk assessment ✓ Safety planning ✓ Telehealth considerations ✓ Red flag presentations ✓ Diagnosis and formulation ✓ Treatment planning ✓ Releases and collateral information ✓ Documentation integrity ✓ Intake packet self-audit If your chart got pulled tomorrow, would it tell the clinical story clearly? Most therapists don't find out their documentation has gaps until it's too late to fix them. This checklist walks you through exactly what a thorough intake should include, what to ask, what to document, and where therapists most often leave themselves exposed. Whether you're a solo practice owner, a group practice, or supervising pre-licensed clinicians, this is the resource you pull out BEFORE the moment you need it. This isn't about fear. It's about being clinically prepared, protecting your clients, and protecting your license. WHO THIS IS FOR ✓ Licensed therapists ✓ Licensed psychologists ✓ Clinical social workers ✓ Marriage and family therapists ✓ Professional clinical counselors ✓ Group practice owners ✓ Clinical supervisors ✓ Pre-licensed clinicians under supervision ✓ Therapists providing telehealth services ✓ Anyone ready to stop saying "I'll remember to ask" and actually tighten their process BONUS: CLINICAL SUPERVISION TIP If you supervise pre-licensed clinicians, this checklist doesn't stop at your own practice. Included is a dedicated Clinical Supervision Tip section built to help you train newer clinicians on risk, telehealth appropriateness, and documentation, so the applied training happens where it actually sticks, inside supervision, not just the classroom. BONUS: VERIFIED RESOURCE LINKS No guessing where to go for the real standards. This resource includes direct, verified links to official APA guidance on documentation, ethics, and telehealth, so you're not piecing this together from outdated blog posts. Grab it, tighten your process, and stop getting comfortable. All digital product downloads are non-refundable.