Licensed Outpatient Therapist

Comprehensive Clinical Assessments

The very first step in providing outpatient mental health treatment is the Comprehensive Clinical Assessment (CCA).  The purpose of a Comprehensive Clinical Assessment is to provide a face-to face evaluation of an individual's present and past mental health, developmental, and/or substance abuse conditions that results in the issuance of a written report known as a CCA.  This report is generated by filling out all of the areas in the template and is meant to serve as a guiding perspective on the client’s current presenting issues and diagnostic criteria.  All diagnosis must be identified and backed using the DSM-5 criteria for diagnosing (citing symptoms, duration and severity).  Assessments are due within 72 hours of the date of service.

Associate Licensed Clinicians-  All CCA’s done by an associate-level clinician (LPCA, LCSWA) must have it reviewed and “signed off” by the clinical supervisor at Peak Professional Group.  This is done by notifying Pendy via email @ pendy@peakprofessionalgroup.com when the CCA is completed (not signed) and ready for review.  Please do not electronically sign the CCA until it has been endorsed by Pendy.  All corrections are due back within 48 hours of the request.

Treatment Plans

Treatment plans provide the foundation for the on-going treatment must be completed during the initial session with the client.  A treatment plan must have the same initiation as the date of service of the initial assessment.  Clients are sent the Tx Plan Signature Page with the intake paperwork online. If the client/guardian has not signed this online form (school-based), a printed form can be signed and sent back to the support team via email.  Tx Plans are to be developed within 72 hours of the date of service.

Treatment plans should be individualized to the presenting issues of the client and measurable in nature.  It is important to include evidence-based interventions in the treatment plan.  Treatment Planners are available through the practice and you are encouraged to use them to assist in the documentation of the Treatment Plan. 

Treatment Plan Signature Pages must be turned into the office within 72 hours of completion for those who are not securing the forms online.

Progress Notes

Progress notes have been streamlined through the implementation of our Electronic Health Record (EHR) Theranest.  Documentation should always be individualized in nature and should never be copied from another chart or different date of service.  Progress notes are to be completed and electronically signed within 48 hours of the date of service.

Confidentiality

All client information is considered protected and confidential in nature.  Each clinician’s licensing board sets out the rules and regulations of client confidentiality.  Please see your specific board’s Code of Ethics to ensure that you are following guidelines accordingly. 

Furthermore, all information that comes in and out of Ppg is considered private and confidential.  This information includes but is not limited to: forms, case consultation, supervision, invoicing, payroll and insurance rate reimbursements.  It is the explicit understanding that this information remain confidential within the context of the group practice.

Client Scheduling of Appointments

Ppg currently uses Theranest to schedule client appointments.  All client appointments should be entered into this system at least 72 hours before the scheduled appointment.  Failure to do this, will disrupt the overall flow of the office space and could have other significant effects on the workings of the company.  Clients have access to our online scheduler (in some cases) and some may choose to use this system to schedule appointments.  With this in mind, it is each clinician’s responsibility to maintain their office hours and keep these hours updated on a regular basis.  All newly scheduled appointments should be entered within 24 hours of making the appointment, so as to ensure that appointments are not made in a conflicting manner.

Client Communications

Clients have many ways of communicating with clinicians at Ppg.  While Ppg does not set or enforce strict guidelines, it is assumed that general common sense will be used regarding how and when to communicate with client’s.  All official communication should be included in a non-billable note in our current EHR so as to protect all parties.  Clinicians are encouraged to decide and notify the clients that they offer counseling to of the best way to get in touch with their therapist.  Unsecure means of communication are discouraged,

Ethical Issues

Any and all potential ethical issues including but not limited to: reporting, suicide/homicide risk potentials and other potential legal or ethical issues must be discussed with the practice owner and the clinical supervisor to ensure that all potentially involved persons are protected.  If needed, Ppg will seek outside consultation regarding any potential or identified risks. 

Peak’s Policies & Proceedures Manual

It is each clinician’s professional responsibility to review the Policies & Procedures Manual on a regular basis.  The Manual is meant to be a fluid document that is updated and changed as needed by administration.  Peak will maintain a Google document with general updates that will be shared with staff on a regular basis.

Continued Education

All clinicians who are licensed through the State of North Carolina must meet minimum Continued Education requirements in order to maintain their license.  Ppg encourages and supports on-going continued education, understanding the very important role that education plays in the professional role.  Ppg will work with each clinician to ensure that they are given the support needed to make this happen.

Crisis Coverage

Ppg offers 24-hour crisis coverage for all people seeking outpatient mental health services through our office.  We have implemented a Policy (please see) that supports the 24 hour crisis coverage.  All clients are to be notified of this policy upon initiating counseling services.  It should be noted that clients are encouraged to first contact their therapist when experiencing a mental health concern due to clinical necessity.  If the therapist is not available, clients are encouraged to contact our after-hours line at 919-412-5685.

Time away from Office

Self-care is an important part of remaining healthy in the counseling field.  With this in mind, taking time away from the office is important and encouraged.  Therapists are to first notify the practice owner and supervisor of any time off, with as much notice as possible so that case discussions can occur and clients’ clinical needs can also be addressed.  Please notify the practice owner of any time off of more than 3-4 days and notify clients of this if you unable to attend to general issues while you are “off”.  If you have any questions about this, let us know and we will discuss this further.

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