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13 Private Practice Paperwork Essentials

This week on the podcast, we added a Part 2 to enhance our discussion on reducing liabilities with health care law attorney, Steven Ballinger.  If you haven’t already heard his podcast on risk management and liability reduction, you definitely want to check it out, click here.  

We are 2 clinicians who built our 6 figure full fee practices from the ground up.  We're passionate about helping other clinicians do the same.  Our values are quality, passion, and collaboration. We are passionate about collaborating with clinicians to ensure they create quality, competent paperwork that meets the legal and ethical standards for our field.  It took us 10+ years to perfect our paperwork and then we took it up a notch by working with family law and health care law attorneys to bring it up to full legal, ethical, and competence standards.  We practice at the highest standards and feel strongly about supporting other therapists to help ensure they do as well.  That is why we are passionate about helping other mental health professionals on their journey from startup to mastery!

All that being said, you are in the right place if you have questions about private practice paperwork!  Are you wondering what to include in your own paperwork?  Curious if you should do it on your own? Perhaps go out and purchase one, or have an attorney draft it up?  We have answers for all of your questions, and more with the 13 Private Practice Paperwork Essentials.

Starting off with some common costly mistakes when creating your own paperwork…

We are clinicians, not attorneys.  We aren’t experts with deciphering legal jargon.  Therefore, make sure you are working with people who can provide that service for you.  With all that considered, be sensitive to the fact that attorney’s fees are typically $300+ per hour.  Picture the paperwork taking ten hours of their time, and equating out to $3,000.  Imagine what you could be doing with that kind of cash if you were to avoid the costly attorneys!

So what else can you do?

Using someone else’s paperwork may be outdated with the current ethics, laws, or rules.  The standards of our profession are constantly changing and evolving.  When you don’t do your own homework, you're at risk of leaving yourself open to liability and decreasing competent care to your clients.  Did you know that therapists incur the most liability in their documentation or lack thereof?   We crafted an Attorney-Approved set of Private Practice Paperwork that is perfected, updated, and ready for you to utilize in your practice!  If you're wanting to take matters into your own hands by researching your own personal private practice, take a look at these tips below.

Let’s go over the basic, necessary (and lengthy) paperwork essentials for all you eager clinicians!

  1. Welcome Letter For this section, you should discuss your style of therapy, therapy philosophies, what your client can expect, and perhaps even maybe a picture of yourself!  Invite them into your space by being authentically and naturally YOU. This is certainly a nice little touch to make clients feel more connected to you before their first session and it is an excellent way to eliminate the stigma of ‘going to a therapist’.

  2. Therapy Agreement -Address the Therapeutic Process: The expectations, risks and benefits, structure and length of therapy, cancellation policy, fee structure (meaning how to handle trial, litigation, appearances, charge for copy of medical records), your availability as a therapist, emergency contacts, insurance policies, the specific treatment done for minors, and so on... -This includes the consent and policies of your services.  It is imperative that you review this with your clients, since you are not able to work with them without them signing this document. -It's vital to go over the consent fully and highlight the major areas with each new client. -Don’t forget about a policy on how to handle dual relationships! -Make sure you have a social media policy. The AMHCA released new ethics as of October 2015 and have done a comprehensive job of addressing technology. ------Create a policy for court orders and how you'll handle it if you get one for a client.  How many times are you going to reach out to them?  What should you do if this happens?

  3. Biopsychosocial / Intake Form -This will be filled with the demographics of your clients.  It will need to include specific questions regarding the biological, social, spiritual, medical, etc. information.  Be sure to ask the right questions for suicidal or homicidal ideations, past, present, etc. (super necessary), and take the time to cater that for your own distinct population.  For example: if you work with couples or substance abuse you may have different assessments for those particular populations.

  4. HIPAA – FREE GIFT (Whoop Whoop!) -This is a MUST!  Guess what Startup Nation!?!  We have a free gift for you. Check the bottom of this page for details.

  5. Process & Progress Notes Template -As clinicians we must document our sessions.  Having a template can help make your note taking more efficient, saving you time and money! 

  6. Release of Information -In the case that you are collaborating with others outside of just working with your client(s), you must have a written release.  

  7. Treatment Plan -If you are working with insurance, this is crucial!  If you aren't, then it is not necessary, but we recommend it anyway as a treatment plan provides goals and directions for therapy.  

  8. Documentation and Communication Form -This will include any communication from your client, a doctor, a family member, a reschedule, an email, anything.  Document, document, document!!  Did you know that emails are part of the medical record?  Make sure you have them documented.  

  9. Discharge & Termination Summary

  10. Suicide Risk Assessment / Client Treatment Compliance Agreement

  11. Letter of Progress -An example of this would be a client who has a court case.  Or perhaps a mom having her child taken away.  The court requires you to do certain things such as document the date, the type of service, goals, progress, or lack of progress towards that goal, and so on.

  12. Videotaping Consent -There are many reasons a therapist might want to video tape a session.  Of course we need our client’s written consent before we video tape.  

  13. Online or Phone Therapy Consent -You must have a consent form specifically tailored to address issues regarding online therapy or phone therapy. This is often in addition to the other items that need to be in your overall consent, policies and agreements.  You should entail things such as how you will handle the session if there is a technological interruption, limits of confidentiality, risks with technology, etc.


We wanted to thank-you for checking out our blog.  We hope this has inspired you to think about your paperwork assuring it is of the highest quality.  We offer our HIPAA form for free, this is a great way to become acquainted with our paperwork in case you purchasing it is an option for you.  Text “FREEHIPAA” to 44222 and you will receive a confirmation text.  Once you respond to that text with your email address, our HIPAA form will be emailed to you instantly.  Enjoy!

We offer our paperwork:

  • A la Carte - cherry pick the best of the paperwork to fit your particular practice needs.  CLICK HERE to find out more.

  • Our “Base Package” creates a solid documentation foundation.  It includes the necessary documents needed to run a private practice and essential forms to start seeing clients.  CLICK HERE to get the Base Package.  One last thing, we have a BONUS GIVEAWAY with $40 off our Base Package!!l!  When checking out enter SAVE40.

  • Our “Peak Package” is a comprehensive package that has every single documentation needed in private practice,  CLICK HERE to get the Peak Package.  This includes the necessary insurance documents as well.  Here's the BONUS GIVEAWAY DISCOUNT of $80 off this deal!!! When checking out enter SAVE80.

If you have any questions about the forms or paperwork, reach out to us,  We are giving you all an opportunity to alleviate stress, save time and money, reduce liability, practice up to the legal standards, and handle risk management!!

We want to also reach out and invite you to join our Private Practice Startup Facebook group.  Here we share valuable information, build resources, and inspire each other’s journeys from startup to mastery!

Don’t forget to check out the podcast on this blog.


CLICK HERE to listen to our other podcasts!  Assure you subscribe so you can stay in the loop of ALL the podcasts we release.  The Private Practice Startup would also be super grateful if you could rate and review our podcasts.  We are trying to be the next "New & Noteworthy" - thanks again for allowing us to Inspire YOU from Startup to Mastery!

~Dr. Kate, Katie & The Private Practice Startup Team



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