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Non - Direct Care

Documentation

Each session for a client is documented with a standard progress note. This note details the client's behavior, therapist observations, client symptoms/affect, and plans for treatment and clients.
In addition, collaboration/consultation notes are also kept and each contact that is made in regards to a particular client is documented. Intake forms, consent forms, releases, assessment results, history and treatment plans are all kept within a patient's file.
In addition, correspondence from medical, education or other human service professionals are also kept in the client file. All copies of correspondence that goes out to these professionals are also kept on file. Letters of termination or referrals are kept on file as well.
Clients are sent satisfaction surveys upon completion of treatment. The office manager gathers this information. In addition, the office manager compiles client demographics and total client data on a monthly basis. Each client is assigned a number. We have the capability to break down information by country of origin, case manager assigned, number, therapist assigned, age, gender and number of total sessions for the center per month, per year cumulative and per patient.