Documentation

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

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

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

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

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

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

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