Operations Manual

A. Telephone or Email Engagement with New Clients

When clients reach out for services, please engage them in the following dialogue; remember that we never know if a client is suicidal, self-harming or in a serious crisis:

  1. Is the client in crisis now? Is s/he safe?
  2. If a crisis occurs, you can call back any time
  3. You can call 911 or go to any hospital emergency room
  4. In Georgia, you can call GCAL – Georgia Crisis and Access Line 1-800-715-4225 which is manned with live counselors 24/7
  5. If you or any one you know is it crisis, we have a free downloadable book for crisis support called “Self Care Guide” at OrchardHumanServices.org/forms or find the “forms” page under the “about” tab at OrchardHumanServices.org
  6. New client forms can be found at OrchardHumanServices.org/forms or by going to website OrchardHumanServices.org and selecting tab “About” and selecting option “Forms” underneath.

B. Lawful and Ethical Practices

All staff, contractors, clinicians, volunteers, consultants, board members, administrators, employees, and stakeholders of Orchard Human Services, Inc. shall abide by the laws and ethical practices that apply to the fields of mental health, human services, education, and public wellbeing. All online services shall be conducted within the organization’s designated telemental health format, which is currently Zoom; and each clinician and practitioner shall use password protected internet services to access the telemental health platform. Any and all electronic devices and records shall be password protected. Included in the lawful and ethical practices to which all individuals shall adhere are the following:

  • Mandated Reporting
  • Child Find
  • FAPE
  • LRE
  • ADA
  • IDEA

C. Disclosures During Initial Session

Licensed clinicians and/or Clinical Interns under supervision shall make the following disclosures at the beginning of care without fail; if the client is unable to comprehend the disclosure due to age or mental status, the clinician shall make the disclosure to a guardian or other authorized representative. [NOTE: Disclosures for Clinical Interns shall be addressed under separate cover; see Rashonda Douthit, Internship Director for details.]

Please DOCUMENT in Theranest as you share the following disclosures with a notation like “Reviewed disclosures for therapist licensure; exceptions to confidentiality; telemental health.”

  • My license is {LPC, LCSW, LMFT, Psychologist}
  • This session is confidential; I will keep your information private to the extent allowed by law
  • I am a mandated reporter; if someone is a danger to self or others, I am required to report it to get help
  • A judge could order that your records be provided to a court under certain circumstances
  • [If the client is a minor] I will keep your privacy, but if you tell me about something dangerous or that puts you or someone else in danger, I may have to find a way to keep you or others safe. [I use a silly example of the client saying he was going to eat a moldy sandwich from under his bed; I explain that I would tell his parents to look under the bed and check what the client eats – then call me when they find it – without exposing the client’s privacy.]
    • This is a {Zoom, MeetUp, Theranest} Telemental Health Session
    • We are using all the protections we know about to keep your session private
    • If at the end of the first session, you do not like telemental health services, you can stop services without being charged and go find an in-person provider
    • Even though we are using all the protections we know about to keep your session private, nobody can guarantee absolute privacy over the Internet. So if you have something that you absolutely need to keep private, please ask to speak over the phone away from the camera.

D. Documenting Services in Theranest

  1. Appointments are coded as “Multi Staff” when two more more team members participate; or a “Therapist” code is used when the clinician sees the client alone. These practices will shift after we switch to a group provider under the insurance companies.
  2. On the day of an appointment, the clinician, intern, or interventionist shall indicate if the appointment was held, missed, rescheduled within Theranest.
  3. Session notes shall be recorded same day [by law, within 24 hours] by the licensed clinician in attendance or clinical intern if authorized by his or her clinical supervisor.
  4. Only sessions with timely notes shall be billed to the client or insurance company; sessions conducted without timely compliant notes shall not be billed nor shall the clinicians/interventionist receive payment for under-documented sessions.
  5. If client presents with any indication of suicidality or homicidality or related ideations, please complete the Columbia Suicide Assessment [in Theranest]. If client presents with anxiety, please complete the GAD-7 [in Theranest]. For depression, please choose one of the depression scales such as Beck or Hamilton from our Assessment materials, which be found in the drive for the email Therapy@OrchardHumanServices.org.
  6. During intake, the Licensed Clinician/Clinical Intern shall complete the Initial Assessment & Diagnostic Codes and Treatment Plans sections of Theranest. Please note that in Georgia, only a licensed practitioner can diagnose; so interns must seek diagnosis codes from one of the licensed clinicians. If the intake and case conceptualization extend beyond the first session, the Treat Plans can be completed on a subsequent visit near the beginning of care.
  7. Following are the 3 major “Progress Notes” sections to be completed each day in addition to any relevant information under Mental Status and Risk Assessment sections.

Session Focus – Section of Theranest

1. Initials of licensed clinician with license type:
If licensed clinician is co-serving with non-clinical staff:
[DCW LPC; GP-DevInt]
If the licensed clinician is supervising an Intern, please document:
[DCW LPC; JD-Intern]
MORE ON STAFF PRESENT - Licensed clinician goes first always;
please do NOT use brackets [ ]; we add brackets to reflect billing
2. Who was present and when were they present:
Example: Client with dad first 20 min; dad alone rest of session.
If privacy is an issue, address "with earbuds in family room"
3. Format of session - Zoom, Phone, etc.
4. Brief synopsis of content of session:
Example: Client discussed school; getting along better with parents.
NOTE - Does not include any therapeutic response, which goes
in next box. For example, if a child was very shy and the therapist
played a game to calm her and draw her out, the game could be
briefly mentioned in box one, but would need to be explained
in box 2 about "Therapy Intervention"

Therapeutic Intervention – Section

  1. Document the clinical content of the session; the licensed clinician may document a separate clinical focus from the interventionist, but the Licensed Clinician or Licensed Clinician/Clinical Intern dyad is responsible for the accuracy of the entire note.
  2. State specific components of Treatment Plan or other specific clinical intervention as determined necessary by clinician during session.
  3. If the developmental interventionist includes a separate note, please indicate with [JB Dev Int – Begin] Notes … Notes … Notes [JB Dev Int – End]. The licensed person is ultimately responsible for the accuracy of your notes, so please check with the clinical lead before posting notes. Following are examples of developmental intervention phraseology that might appear in the notes:
    • Academic engagement
    • Activities of daily living
    • Attachment development
    • Attention
    • Auditory processing – Expresive
    • Auditory processing – Receptive
    • Bonding
    • Cause & effect
    • Cognitive development
    • Compassion for self & others
    • Communication
    • Compliance & following directions
    • Comprehension
    • Cooperation
    • Emotional IQ [Vocal, facial, postural, movement, tonal emotional identification]
    • Empathy
    • Ethical & moral development
    • Executive function
    • Executive skills
      • Inhibit Distractors
      • Planning
      • Sequence
      • Working Memory
    • Eye gaze
    • Focus
    • Friendship
    • Impulse control
    • Inhibition
    • Interoceptive regulation
    • Lawful awareness & behaviors; citizenship
    • Logic
    • Meditation
    • Memory
    • Metacognition
    • Mindfulness
    • Motor – fine
    • Motor – fine
    • Organization & planning
    • Proprioception
    • Prosocial behaviors
    • Reasoning
    • Relational capacities
    • Safety
    • Secure base
    • Self-awareness
    • Self-calming
    • Self-determination
    • Self-esteem
    • Self-regulation
    • Self-soothing
    • Sensory integration
    • Sensory processing
    • Sequencing
    • Sharing & taking turns
    • Socialization
    • Teamwork & collaboration
    • Theory of Mind [TOM]
    • Trust
    • Vestibular functioning
    • Visual processing
  4. For services with an academic focus, please maintain the academic portion of your records in a separate record keeping system. Theranest is only for the clinical portion of client records; the developmental component of academic learning is included in Theranest as it is a clinical component of complex services. Academic means Math, Social Studies, English, etc..

Planned Intervention – Section

Licensed Clinicians/Clinical Interns, please indicate next steps, i.e. continue care plan, conduct GAD next session, refer to Developmental Pediatrician, etc. This section can be brief or may include a more complex plan to direct the next session. If this section includes critical information to direct next sessions, please consider adding this information to the Therapy Plan.

Minimum accepted response to Planned Intervention Section:

“Continue with treatment plan”

Mental Status – Section

Licensed Clinicians/Clinical Interns ONLY please complete the Mental Status section as appropriate. Please think about where these records will be used, such as in court, with insurance, with another facility that may serve the client. NOTE: Interns must be cleared and authorized by Rashonda Clay-Douthit to complete Mental Status section on an individual basis as part of the supervision process.

Risk Assessment – Section

Please indicate status of risk each session; if clinician asks client directly, and client denies having thoughts of harming or taking life of self or others, then please choose the selection “Client denies ….. “

If for some reason you are unable to overtly ask (because a younger sibling was in the room), but you are certain the client is stable, please choose “Not Present”

If you are unable to determine for some factor related to the client, like client is too young, client in a public place, client is not alone in session, please choose “Unable to determine”

Licensed Clinicians/Clinical Interns ONLY, please complete the Risk Assessment section every time. Ask the questions in a positive and direct manner such as: “Do you have any thoughts of harming yourself or others or of ending yours or someone else’s life?”

Do NOT ask about risk in the following manner, “You’re not going to hurt yourself, are you?”. This is against best practices and shall never be our approach to Risk Assessment. If anyone has questions, please see Darleen Wodzenski or Rashonda Clay-Douthit for clarification.

If you are unable to assess risk for some reason such as the session not being private or confidential, the client being too young, or any other reason, please indicate that option in Theranest. If you need additional options included, please let administrative staff know.

Comments are closed.