Therapist Resource Hub

Note Types

Common clinical documentation formats used by therapists to record and track client sessions.

7 resources

Assessments

Standardised assessment tools and frameworks for evaluating client needs and progress.

7 resources

Compliance

Regulatory requirements, ethical guidelines, and legal obligations for therapy practices.

6 resources

Practice Management

Operational best practices for running and growing a therapy practice.

8 resources

BIRP Notes

A BIRP note documents therapy sessions in four sections: Behaviour, Intervention, Response, and Plan — focusing on what happened and how the client responded.

Note Types

Cancellation and No-Show Policy

A cancellation and no-show policy defines the notice period required to cancel a therapy session and the fees charged for late cancellations or missed appointments.

Practice Management

Client Confidentiality

Client confidentiality is the ethical and legal obligation for therapists to protect all information shared by clients during therapy from unauthorised disclosure.

Compliance

Client Intake Process

The client intake process is the sequence of administrative and clinical steps that onboard a new therapy client, from initial contact through the first session.

Practice Management

Clinical Supervision

Clinical supervision is the formal, evaluative relationship in which an experienced therapist oversees and supports the professional development of a trainee or supervisee.

Practice Management

DAP Notes

A DAP note is a streamlined clinical documentation format with three sections: Data, Assessment, and Plan — combining subjective and objective information.

Note Types

Duty to Warn and Duty to Protect

Duty to warn and duty to protect are legal obligations requiring therapists to take action when a client poses a credible threat of serious harm to an identifiable third party.

Compliance

GAD-7: Anxiety Screening

The GAD-7 (Generalised Anxiety Disorder-7) is a seven-item self-report measure used to screen for anxiety severity, scored 0-21, commonly paired with the PHQ-9.

Assessments

GIRP Notes

A GIRP note is a goal-oriented documentation format with four sections: Goals, Intervention, Response, and Plan — tying every session to treatment objectives.

Note Types

HIPAA Compliance for Therapists

HIPAA (Health Insurance Portability and Accountability Act) sets standards for protecting sensitive patient health information that therapists must follow.

Compliance

Informed Consent

Informed consent in therapy is the process of ensuring clients understand and agree to the nature, risks, benefits, and limits of treatment before therapy begins.

Compliance

Initial Intake Assessment

An initial intake assessment is the first comprehensive evaluation conducted when a new client begins therapy, gathering history, presenting concerns, and treatment goals.

Assessments

Insurance Billing and Superbilling

Insurance billing covers the process of submitting claims to insurance companies for therapy reimbursement, while superbilling provides clients with documentation to seek out-of-network reimbursement.

Practice Management

Mandatory Reporting

Mandatory reporting is the legal obligation for therapists to report suspected child abuse, elder abuse, and other specified harms to the appropriate authorities.

Compliance

Mental Status Exam

A Mental Status Exam (MSE) is a structured assessment of a client's cognitive and emotional functioning at a specific point in time, covering appearance, mood, thought, and cognition.

Assessments

PCL-5: PTSD Screening

The PCL-5 (PTSD Checklist for DSM-5) is a 20-item self-report measure for assessing PTSD symptom severity across all four DSM-5 symptom clusters, scored 0-80.

Assessments

PHQ-9: Depression Screening

The PHQ-9 (Patient Health Questionnaire-9) is a nine-item self-report measure used to screen for depression severity, scored 0-27, widely used in routine outcome monitoring.

Assessments

Progress Notes

Progress notes are clinical records that document a client's treatment progress over time, including session summaries, interventions, and outcomes.

Note Types

Psychotherapy Notes

Psychotherapy notes are a therapist's private process notes about a client's session, granted special protection under HIPAA and stored separately from the clinical record.

Note Types

Record Retention Requirements

Record retention requirements define how long therapists must keep client records after treatment ends, typically 7-10 years for adults and longer for minors.

Compliance

Risk Assessment and Safety Planning

Risk assessment is the clinical evaluation of a client's potential for self-harm, suicide, or harm to others, guiding safety planning and intervention decisions.

Assessments

SOAP Notes

A SOAP note is a structured method of clinical documentation that organises session information into four sections: Subjective, Objective, Assessment, and Plan.

Note Types

Session Documentation

Session documentation is the process of recording clinical information from therapy sessions, including notes, assessments, and treatment updates.

Practice Management

Sliding Scale Fee Structure

A sliding scale fee structure is a tiered pricing system where therapy session fees are adjusted based on the client's household income, expanding access while maintaining practice viability.

Practice Management

Teletherapy Best Practices

Teletherapy is the delivery of therapy services through video conferencing or other digital platforms, requiring specific technical, ethical, and clinical considerations.

Practice Management

Termination Notes

A termination note is a clinical summary written at the end of treatment that documents the reason for ending therapy, progress made, and referrals provided.

Note Types

Treatment Plans

A treatment plan is a structured document that outlines a client's diagnoses, therapeutic goals, interventions, and measurable objectives to guide the course of therapy.

Assessments

Waitlist Management

Waitlist management is the structured process of screening, communicating with, and prioritising prospective therapy clients who are waiting for an available appointment slot.

Practice Management