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# The Basic Documentation Every Private Practice Needs

Susan Day
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June 16, 2017

## The Basic Documentation Every Private Practice Needs

Working as a private practitioner means you are in charge of each and every process - from intake to therapy sessions.

Each part needs to be properly documented and archived in order to store important information properly and securely, and protect yourself from possible legal implications.

There is an array of forms and documents you will need to develop - and you can check your professional society’s website for suggestions. To get you running off the ground, these are the basic documents you need to start with:

## Intake Form

Basic information about the client (name, birthdate, address etc.) + assessment questions relevant to the specialty of the practice/therapy (e.g. questions related to family structure and practice for Marriage and Family Therapists)

## Informed Consent Acknowledgement

This outlines the type and practice of professional services, as well as confidentiality agreements.

The Basic Documentation Every Private Practice Needs

## Insurance Form

This informs the patient that you will share information with their insurance company in order to receive payment.

## HIPAA acknowledgement

This refers to the Health Insurance Portability & Accountability Act of 1996 and explains the way clients’ private information are handled and shared if appropriate.

## Office Policies and Procedures

This refers to information about your practice’s processes, including treatment termination policies, cancellation processes, return check fee etc.

As you can see there is a lot of paperwork involved in running a private practice - and this is only a start.

If you want to declutter your office and move paperless, use a software package you can trust that will help you with getting your paperwork in order.

Talk to Therasoft today.