Documents and Forms (non-disaster)
Here are links to some of the non-disaster documents and forms we discuss in our clinical supervision and licensure prep classes. Below each link (title) is a brief description of the item. Clicking the links will allow you to view and download the items.
Tired of writing the same old descriptive words/phrases in your progress notes (e.g., client “reported”; therapist “advised”)? Try adding some of these the next time you are writing.
Best Practices for Restful Sleep
Lots of our clients have trouble sleeping. Here is a simple handout you can use as a framework for a discussion about sleep hygiene.
Used to document and track verbal complaints made by clients about the programs and services they are receiving. This can be used for both inteComplaint Process and Form rnal complaints and issues with outside contractors/contract agencies.
Description/Assessment/Plan (DAP) Progress Note
DAP notes are an excellent format for documenting therapeutic contacts with clients. Under “D” report the facts and behavioral observations — what is the client saying/doing and what methods/techniques are you using. The “A” sections is for your impressions and the “P” section is for you future direction.
Intake Attachment (used with both Social History docs listed below)
Used with the self-administered Adult Social History form and the parent/guardian-administered Child/Teen Social History form (see below), the intake worker uses this to add mental status information, initial diagnoses, a brief summary and impressions.
Lots of problem solving methods are available but none of the others caught our eye like this one (author unknown). Originally encountered during a disaster relief operation, this simple and straight-forward approach can be applied to many non-disaster situations.
Being a helping person takes a physical and a psychological toll on the helper. Sadly, many caregivers do not practice basic self care. Save yourself for the long haul. Use these 22 self care tops and share them with your clients and coworkers.
Social History: Adult (self-administered)
Adults (and older teens) can fill this out in advance of an intake appointment. Ask them to arrive 30 minutes early to do this before they are seen. The intake worker can then review it with the client and embellish the incomplete answers. Use the Intake Attachment too (see above).
Social History: Child/Teen (done by parent/guardian)
Parents/guardians can fill this out in advance of an intake appointment. Ask them to arrive 30 minutes early to do this before they are seen. The intake worker can then review it with the family and embellish the incomplete answers. Use the Intake Attachment too (see above).
Staff Meeting /Group Supervision Log
Example of a form that can be used to easily track attendance and topics covered in staff meetings/group supervision sessions. The blank space to the right of the topics list is useful for adding brief notes about what was discussed about each checked item.
Seasoned clinicians generally have their own mental checklist of what to watch for in their clients' stories. This checklist was developed to help students and new therapists with conducting initial diagnostic assessments and crisis sessions. Several of the items listed here are not included in some agencies' typical paperwork and might otherwise be overlooked early in one's practice.
Tracking LCSW Supervision (with case study format)
Form suggested for use by Licensed Clinical Social Workers (LCSW) who are supervising LCSW candidates, to document the issues discussed in each supervisory session, the total hours of clinical practice, and the total hours of supervision provided. Second page is acorresponding case study format.
Treatment Plan Goals, Objectives, and Interventions
Form includes a list of goals and objectives that clients can review, to select things they want to address during their treatment. Once the goals and objectives have been established, the last page is a list of potential interventions that can also be used in the planning process and/or in DAP notes.