Completing the Client Intake Process (TheraNest)

The Client intake process begins with creating the Client record, followed by scheduling their first appointment which provides them with their Intake Documents. Once the intake forms are submitted and the first appointment is completed you can create the Initial Assessment and Treatment Plan.

• Initial Assessment - contains the initial diagnostic impressions and diagnosis code information that populates future progress notes.
• Treatment Plan - pulls in the diagnosis code from the initial assessment. Complete the plan by entering treatment plan length, modality of treatment and documentation of treatment goals.

Initial Assessment and Diagnostic Codes

Before completing the Initial Assessment and Diagnostic Codes form note the following:

1. The field under Diagnostic Impressions is where you select the Diagnostic Code(s). Codes available to select are based on the DSM version you select in the Organization Profile.
   

   IMPORTANT: If you are planning to submit client claims to insurance, the code(s) here will be pulled into the CMS 1500 form for the claim. You cannot submit a claim without a Diagnostic Code.

2. Dynamic Progress Note Forms can be created to include the Diagnostic Code in the Progress Note automatically. Be sure that Diagnostic Codes are included in the Initial Treatment plan to populate the note correctly.
3. Client intake date is generated automatically when the client is created. If this date needs to be changed, it must be done on the Client > Additional Details page.

Treatment Plan

Before completing the Treatment Plan note the following:

1. Diagnostic Impressions field automatically pulls the diagnostic code(s) from the Initial Assessment and Diagnostic Codes. The Initial Assessment should be completed prior to completing the Treatment Plan.
2. Client Goals are added at the bottom of the form.
3. Dynamic Progress Note Forms can be created to include the Client Goals in the Progress Note automatically. Be sure that Client Goals are included here to populate the note correctly.
4. Wiley Practice Planners is an additional TheraNest subscription. This subscription includes Wiley Treatment Planners that can be used in conjunction with Wiley Progress Notes.