James Fitzgerald Therapy PLLC

Compliance with State & Federal Laws and Insurance Rules & Regulations

I try to review this document at least once per week, and during an internal audit, so I continue to adhere to ethical, professional, regulatory, and insurance guidelines. Like many therapists, I might not enjoy documentation, however, I try to be ready for external audits, so this form and my policies and procedures are necessary for both our peace of mind and mental health. Thank you for taking this proactive approach to your treatment.

All my public facing information points people to my websites and client account portal to request an initial intake session. I would like to notify you there is no guarantee that voice mail messages on my voice mail will be heard or responded to promptly, that the best means of communication with me is via email. I continue to offer a free consultation session. I do not offer sliding scale fees per my contracts with insurance panels. For ethical reasons, I do not charge a late cancellation or no-show fee. The intake and compliance documentation has been revised to address these policies.

Your invitation to register for a client account in Therapy Portal

The starting point for any new client into therapy with me is a Therapy Notes’ email invitation to set up a client portal account. From here, you can fill out the necessary intake paperwork. There are several ways I can get you scheduled in our system. If you’re a new client, I can initiate the process by booking you on the calendar. Another option is for me to add you as a new client from the Clients tab in Therapy Notes. I can even add you by clicking the plus sign in the upper right corner of my calendar screen.

Once that’s set up, you’ll receive an email inviting you to create your client portal account. You’ll then be guided through the paperwork, which is very important for your care. This includes entering your demographic information, insurance details, and credit card information for any deductibles or copays. You’ll also read and sign the required legal forms, and complete any questionnaires that help me better understand you and your needs for intake and diagnosis.

I may also request that you fill out release of information (ROI) forms if I need those for your treatment. Everything you submit will be stored in your chart, which helps me reduce data entry on my end. You’ll be able to change your information if necessary, and you’ll also have the option to review or cancel your appointments right from the portal. It’s a secure platform where you and I can communicate privately if you have any questions or concerns about your treatment. I encourage you to get familiar with the portal. If you’d like, you can even set yourself up as a “mock” client with a different email address just to practice. That way, you’ll see everything from your own point of view, and we can address any questions you might have before you begin.

Through your portal account, you’ll be able to see your records, complete any homework assignments I give you, and pay your balances. Please remember that you’ll need to complete your intake paperwork in line with the policies I’ll provide. There’s paperwork to complete before our first intake session and additional paperwork before our second session. After each of our visits, I may also give you reading assignments or homework that I expect you to finish before our next meeting. I appreciate your cooperation, and I’m here to help if you run into any issues.

Setting up Your Client File and Medical Records Chart

Your client file and medical chart in Therapy Notes will contain the following:

• My Public Disclosure Statement as regulated by the VT State Office of Professional Regulation and the Mental Health Professionals licensing board.
• My Notice of Privacy Practices
• My Practice Policies and Procedures
• Informed Consent to Therapy Services
• Vermont Statutes and OPR governing rules
• Counselors Ethical Compliance and Accountability
• Client Manual (multiple PDF files)
• Client Information Form: Demographic Information form (DOB, address, sex, etc.)
• List of Prescribed Medications Vitamins and Supplements
• Client History Form
• ROI for all collateral contacts
• Insurance Information form
• Credit card or payment info if they are not using insurance
• Credit Card Authorization form
• Notice of No Surprises Act
• Informed Consent for Electronic Communication (Phone/Text/Email)
• Informed Consent for Telehealth Services (Zoom Pro)
• Informed Consent for AI Transcription of Sessions
• The Use of UpHeal AI Software to Create Counseling Documentation
• Telehealth Instructions for Zoom and Therapy Portal
• Electronic Library: Information About the Portal Documents and Forms
• Electronic Library: Documents and Forms Table of Contents
• Electronic Library: Terms of Use and Copyright Content Disclaimer
• Therapy Portal: Secure Messages and Electronic Communication

Your orientation to therapy and our sessions together:

You will be asked to read the client manual, which consists of hundreds of pages sorted into separate chapters and chapter sections. Each PDF file is a different section of the manual. Every client is asked to read through the client manual.

My therapy program and treatment progress:

Many of the forms and documents in Therapy Portal are not sharable or always available. The client manual outlines the program from start to finish. It includes any of the approaches or protocols I have training and experience in. You decide which ones you want to work with, and skip the ones you don’t chose. They are always optional.

The completed chart and electronic health records

Every client chart is complete when the following items are completed:

• All intake paperwork requested in the client portal
• Intake Note, Assessments, Integrative Summary (with Mental Status Exam)
• Diagnosis Summary, Therapy Program and Universal Treatment Plan (Client Manual), and Treatment Plan in the EHR. Updated every 60 days or as needed. When a TP is updated, it must be accompanied by a Treatment Review Note.
• Good Faith Estimate (only for cash pay clients)
• Medicare Advance Beneficiary Notice
• Psychotherapy Notes and Progress Notes for each session
• Outcome Measures, Session Evaluations, Therapist Evaluations
• Clients Progress Tracking
• Discharge Summary, when our work is complete.

Guidelines for practice and documentation (flowchart)

If The Golden Thread is maintained, documentation will support each decision, intervention and note, contributing to a complete record of client care that is respectful of client confidentiality, will protect from legal problems, get reimbursed by insurance companies, pass an audit, and reflect the integrity of your work. Beth Rontal LCSW

PRESENTING PROBLEM:

Intake > Assessment > Diagnosis > Treatment Plan > Progress Notes > Discharge Summary

BEHAVIORAL DEFINITIONS:

Intake > Assessment > Diagnosis > Treatment Plan > Progress Notes > Discharge Summary

MEDICAL NECESSITY:

Intake > Assessment > Diagnosis > Treatment Plan > Progress Notes > Discharge Summary

GOALS AND OBJECTIVES:

Treatment Plan > Progress Notes > Discharge Summary

PROGRESS AND PROGNOSIS

Progress Notes > Discharge Summary

Intake & Assessment:

Presenting problem, biopsychosocial and history, medical and mental health history, medications, symptoms, behaviors, severity, medical necessity

Diagnosis, Integrative Summary & Treatment Plan:

Presenting problem, strengths / needs / abilities / preferences, goals and objectives address symptoms, behavioral evidence and severity addressed in goals, medical necessity demonstrated, interventions which address symptoms and behaviors.

Session Progress Note:

Presenting problem, goals and objectives addressed in session, medical necessity maintained, interventions done and how received, progress, prognosis, homework, and plan

Discharge Summary:

Presenting problem, goals and objectives met / not met, progress made / not made, reason for discharge, etc.

The idea is that you want your diagnosis and goals to address the findings of the assessment, those goals need to be addressed in the sessions, and everything must match and flow logically.

Documentation Regulations and Requirements

The following segments are directly from the VT Medicaid Regulations

Documentation

“Each provider must keep written documentation for all medical services, actual case record notes for any services performed, or business records that pertain to members for services provided and payments claimed or received. Providers must document all services provided on the same day of the encounter or within a reasonable time. In this section, “a reasonable time” means within one week of providing the service, unless extenuating circumstances prevent the provider from documenting a service within that time. If extenuating circumstances prevent a provider from documenting a service within one week of providing the service, the provider must also document those extenuating circumstances. All documentation must be legible, contain complete and adequate information and applicable dates.

At minimum, documentation must include:

• Two patient identifiers
• Provider rendering services
• Provider signature, printed name & date
• Providers should reference supplemental manuals as needed

5.3.46.6 Documentation Standards for Mental Health and Substance Abuse Health Records

At a minimum, the documentation in a mental health/substance abuse health record will include the following core components:

1. Identifying data

• Name/unique ID, date of birth, and other demographic information as needed

2. Dates of service

• Documentation by the primary treatment provider of all dates and the amount of time clinical services were provided

3. Comprehensive clinical assessment (e.g., biopsychosocial, medical history, etc.)

• Due within 1 week of intake. Evidence that a comprehensive clinical assessment has been completed, with documentation of a presenting problem and patient placement to support clinical level of care, such as:
  • Outpatient
  • Intensive outpatient
  • Partial hospitalization
  • Residential
  • Inpatient
• Evidence of ongoing reassessment as needed

4. Treatment and continued care planning

• Due within 1 week of intake and to be updated as needed.
• Documentation of treatment plan, including the following:
  • Prioritization of problems and needs
  • Evidence that goals and objectives are related to the assessment
  • Evidence that goals and objectives are individualized, specific, and measurable, with realistic timeframes for achievement
  • Specific follow-up planning, including but not limited to anticipated response to treatment, additional or alternative treatment interventions, and coordination with other treatment providers

5. Progress Notes

• Due within 1 week from DOS. Documentation supporting continued need for services based on clinical necessity, including the following:
• 2020-04-01 General Billing and Forms Manual 87
  • Dated progress notes that link to initial treatment plan
  • Updates or modifications to treatment plan
  • Interventions provided and client’s response
  • Printed staff name and signature or electronic equivalent

Assessment

So much of what I do in session is assessment, that it’s hard to think about it in terms of documentation sometimes. When I sit with my client, I am constantly forensically observing them, to do my job, and it’s all “assessment”, really. Beyond the initial Intake Assessment that I do, I am continually assessing the client’s progress in the treatment plan updates and in progress notes, and I do this with narrative and non-narrative forms.

Narrative Forms of Assessment

Anywhere in my documentation where I assess a client’s state or progress, I can do so with a brief narrative example; just a sentence or two. These statements relate directly to the subjective content brought by the client, maybe a quote from them, for example. It can explain how the client responded to the session, and describe *my* understanding of what happened in the session.

Examples:

• Client’s sense of aloneness seems to be reinforced by financial stress and fears. He may lose focus as a protection from feeling alone and hopeless.
• Client’s anger at himself may impact his ability to focus, which impacts feeling connected to self/others.
• It’s possible the client reports feeling better because he has a plan of action.
• Client appeared open to strategies discussed.

Non-Narrative Assessment

In addition to narrative assessments, I may report certain things with the efficiency of a multiple-choice answer. These are never sufficient on their own, but can make assessment quite streamlined.

Examples:

• Response to TP (1 poor, 5 excellent) 1 2 3 4 5
• Response to meds (1 poor, 5 excellent) 1 2 3 4 5
• Ability to be independent with new skills/abilities (1 poor, 5 excellent) 1 2 3 4 5

Assessment content areas

Identifying Information: Basic demographic details of the individual, including name, age, address, and contact information.

Presenting Problem: A description of the individual’s current mental health concerns or symptoms that led to the assessment.

History of Presenting Problem: Details about the onset, duration, and severity of the presenting problem, as well as any triggering events or factors.

Psychiatric History: Information about the individual’s past and current psychiatric diagnoses, treatments, hospitalizations, and medications.

Medical History: Relevant medical history, including any physical health conditions or medications that may impact mental health.

Mental Status Examination: An evaluation of the individual’s appearance, behavior, mood, affect, thought content, cognition, and insight.

Substance Use History: Information about the individual’s history of substance use, including alcohol and drugs.

Social History: Details about the individual’s living situation, family dynamics, social supports, and any significant life events.

Trauma History: Information about any history of trauma, abuse, or adverse childhood experiences.

Risk Assessment: Evaluation of the individual’s risk of harm to self or others, including any current suicidal or homicidal ideation.

Diagnostic Impressions: Provisional or final psychiatric diagnoses based on the assessment findings and diagnostic criteria.

Treatment Recommendations: Recommendations for mental health treatment, including therapy, medication, and other interventions.

Prognosis: Assessment of the individual’s prognosis for recovery or improvement with treatment.

Documentation of Consent: Documentation of the individual’s consent for assessment and treatment, as required by law and ethical guidelines.

Diagnosis and the Diagnostic & Integrative Summary

It seems some professionals feel uncomfortable with diagnosing clients, and tend to steer clear of it as much as possible by using the Adjustment Disorder diagnosis whenever possible. I need to stay accurate, honest and ethical in the diagnosis process, first and foremost. Failing to accurately diagnose someone because of personal discomfort is unethical, and leads to a treatment plan that doesn’t do justice to the client. That said, since there are sometimes multiple diagnoses that could be considered appropriate for a given client, care should be given to making the right choice.

The diagnosis I use goes into your medical record and is searchable through their insurer by anyone authorized to do so. The codes in this record could impact someone’s ability to:

• Adopt a child
• Buy a life insurance policy
• Qualify for certain jobs or promotions

I might wait sometimes to make a more serious diagnosis until I am very sure of it, by making a provisional diagnosis to start with. I will make a Treatment Review Note and a new Treatment Plan when I do make the change.

I never go back and change an old treatment plan!

Diagnosis checklist

When I am making a diagnosis, I determine whether your symptoms and behavioral examples support the diagnosis, and this must meet the criteria for the diagnosis in the DSM 5 TR. I also note the level of impact of severity.

• The symptoms must support the diagnosis
• The client must meet enough of the criteria to support the diagnosis
• Rate for Severity- Mild, Moderate, Marked, Severe, Extreme
• Frequency- %, daily, weekly, 2x/day, etc
• Intensity- Mild, Moderate, Marked, Severe, Extreme
• Duration- 1 week, 6 months, beginning in childhood, onset at age 21
• Behavioral examples in behavioral language

Treatment Planning

What’s the Point?

Treatment plans are important for many reasons:

• Treatment plans provide a process guide to how counseling will be delivered.
• Professionals who do not use treatment plans are at risk for fraud, waste, and abuse, and they could potentially cause harm to their clients.
• Implementing a plan for treatment can protect both you, your supervisor, and your client, as it ensures that all parties involved have a clear understanding of the progress being made and long-term goals.
• Treatment plans provide a summary of services provided, so counselors can use treatment plans as supportive documentation for billing, if necessary.

Medicaid and MVP, like most insurers, require that treatment plans be completed for every person in treatment. Each insurer offers specific guidelines regarding what should go into a treatment plan and how frequently plans should be updated and reviewed. VT Medicaid requires them to be updated “as clinically necessary.”

I will ask you to help me track your progress since the last treatment plan was written. If there has been a lack of progress or a regression, I’ll be sure to document that carefully.

Effective Mental Health Treatment Plans Contain the Following:

History, assessment, and demographics:

• This section can include basic demographic information, psychosocial history, onset of symptoms, diagnoses (past and present), treatment history, and any other assessment information pertinent to well-being. If the client has seen a counselor or other mental health professional in the past, you’ll describe their prior treatment history.

Presenting concerns:

This section details the current concerns and mental health issues that led the individual to seek treatment. Ask: “Why now?”

Treatment contract:

The treatment contract summarizes the goals for change, often a mutually agreed-upon plan for what will be worked on. It usually details who is responsible for what, as well as what treatment modality will be used.

Strengths:

Throughout the plan, practitioners often include information about the perceived strengths of the person in treatment. This can empower individuals to tap into their areas of strength to achieve their goals.

Modality, frequency, and targets:

Throughout the plan, each goal typically includes the type of treatment modality that will be used to achieve it. The frequency of sessions and target dates for completion are also often included.

Treatment goals:

Goals are the building blocks of the treatment plan. They are designed to be specific, realistic, and tailored to the needs of the person in therapy. The language should also meet the person on their level. Goals are usually measurable—rating scales, target percentages, and behavioral tracking can be incorporated into the goal language to ensure that it is measurable.

Objectives:

Goals are often broken down into objectives in order to support the person in therapy through the process of taking small, achievable steps toward the completion of the larger goal.

Interventions:

Goals usually also include the various techniques and interventions the mental health professional will implement in order to support achievement of the larger goal.

Progress and outcomes:

Documenting progress toward goals is considered to be one of the most important aspects of a mental health treatment plan. Progress and outcomes of the work are typically documented under each goal. When the treatment plan is reviewed, the progress sections summarize how things are going within and outside of sessions. This portion of the treatment plan will often intersect with clinical progress notes.

When and how often should I update my Treatment Plan?

In Vermont, Medicaid requires that a TP be written with 30 days of intake, and that it be updated “as clinically necessary.” But what does that really mean? There are some circumstances where a change will be obvious:

• The client discloses information which changes their diagnosis or goals
• The client’s circumstances change in a way that warrants a change to the TP
• The normal course of treatment leads from one set of objectives to another to meet the goals

And then there are these less obvious, but equally important to make changes to the TP.

For these, we can apply the Rule of Three

• If a service not on the TP occurs more than 3 times, add it to the TP
• When an intervention is not part of the TP more than 3 times, add it
• If different services are needed more than 3 times, add it

Conclusion

In conclusion, I appreciate that you have reviewed these policies and procedures with care. This thorough overview was designed to support a well-organized, ethical, and transparent therapeutic process. Your willingness to engage with the materials in the Therapy Notes portal, complete necessary paperwork, and collaborate on a detailed treatment plan underscores your commitment to proactive mental health care.

I appreciate your intention to continue adhering to federal, state, and insurance regulations, particularly Vermont Medicaid and Medicare guidelines, in order to ensure your documentation and care are fully compliant. By establishing clear expectations around documentation, assessment, treatment planning, and ongoing progress evaluations, I strive to safeguard your well-being and confidentiality while promoting meaningful therapeutic outcomes.

Throughout this handout, you were guided through the rationale behind each step in the intake and treatment journey, emphasizing that every document and task connects logically to the next—what is often called “The Golden Thread” in mental health services. This process safeguards your rights, fosters clinically informed decision-making, and supports the integrity of the therapeutic relationship. I remain steadfastly dedicated to improving these policies and procedures, reviewing them regularly to align with the latest ethical, regulatory, and clinical best practices. The goal is not only to comply with professional standards but also to honor your right to accessible, respectful, and evidence-based care. As you prepare for treatment or continue in therapy, I’m ready to address any questions or concerns, ensuring you feel empowered and well-informed every step of the way.

References

American Counseling Association. (2014). ACA Code of Ethics. American Counseling Association.

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Publishing.

Centers for Medicare & Medicaid Services. (n.d.). Medicaid Documentation for Behavioral Health Services. www.medicaid.gov

Vermont Office of Professional Regulation. (n.d.). Mental Health Professionals Statutes and Rules. https://sos.vermont.gov/opr/

Vermont State Medicaid Regulations. (n.d.). Documentation Requirements. Vermont Department of Vermont Health Access.

Rontal, B. (n.d.). “The Golden Thread” Philosophy. Vital Therapy.