What's the difference between an intake form and a screening tool?

An intake form collects comprehensive background information, demographics, and treatment history to establish care. Screening tools (like PHQ-9 for depression or GAD-7 for anxiety) are standardized assessments that measure specific symptoms or risk factors. Many practices use both: intake forms for general information and screening tools for clinical assessment and ongoing progress monitoring.

Can clients complete intake forms at home before their first session?

Yes, many practices now offer online intake forms that clients can complete from home before their first session. This approach saves valuable session time and allows clients to thoughtfully consider their responses without feeling rushed. Solutions like ICANotes provide a secure patient portal where clients can access and complete comprehensive intake forms, including psychiatric history, medical history, and social/developmental background. The portal supports electronic signatures and automatically populates submitted information into the client's record. When selecting an online platform, prioritize solutions that are designed and maintained to be HIPAA-compliant , such as ICANotes, and always review completed forms with clients during their first visit to clarify information and address any questions.

Are there different intake forms needed for minors versus adults?

Yes, intake forms for minors (under 18) require additional considerations including parental/guardian consent, developmental history sections, school performance questions, and family dynamics assessments. You'll also need separate consent forms from both the minor (when age-appropriate) and their legal guardian. Some states have specific requirements for treating minors , so check your local regulations.

How often should intake forms be updated or revised?

Review and update your intake forms annually or whenever regulations change. Consider revising forms based on client feedback, new treatment modalities you offer, insurance requirements, or changes in best practices. Keep previous versions dated and stored securely, as you may need them for clients who completed older versions.

What happens if a client refuses to fill out certain sections of the intake form?

Clients have the right to decline answering specific questions, though this may limit your ability to provide comprehensive care. Address their concerns empathetically, explain why certain information is important for their treatment, and respect their boundaries. You can note "client declined to answer" in your records and revisit sensitive topics as the therapeutic relationship develops and trust is established.

What are the most common mistakes clinicians make when filling out superbills?

Some of the most common mistakes clinicians make when completing superbills include missing or incorrect client information, using invalid or outdated CPT or diagnosis codes, and omitting essential provider credentials such as NPI numbers or licensure details. Other frequent errors include listing non-reimbursable services, failing to specify the date or duration of service, or not aligning service codes with the documented session type. These mistakes can delay or prevent clients from receiving reimbursement from their insurance provider. To avoid issues, clinicians should ensure that superbills are accurate, complete, and consistent with session notes and billing requirements. Using a superbill template designed for mental health services can help minimize errors and streamline the process.

How detailed does the diagnosis or session description need to be on a superbill?

A superbill should include the ICD-10 diagnosis code(s) rather than a narrative description of the diagnosis. This standardized coding allows insurance companies to quickly process claims. For session descriptions, clinicians should use the appropriate CPT code(s) that reflect the type and duration of the service provided—for example, 90837 for a 60-minute individual psychotherapy session. Detailed clinical notes are not required on the superbill and should be kept separate in the client’s health record. Keeping the superbill clear, concise, and code-based helps protect client confidentiality while ensuring accurate reimbursement processing.

Can clients submit a superbill for sliding scale or reduced fee sessions?

Yes, clients can submit a superbill for sliding scale or reduced fee sessions, but whether they receive reimbursement depends on their insurance plan. Most insurance companies base reimbursement on the actual amount paid, not the provider’s standard rate. That means if the client paid a reduced fee, the reimbursement will likely be calculated from that lower amount, if it qualifies for reimbursement at all. It’s important to reflect the exact amount paid on the superbill and advise clients to check with their insurance provider to understand how reduced-fee services are handled under their plan.

Do insurance companies always reimburse for out-of-network therapy with a superbill?

No, insurance companies do not always reimburse for out-of-network therapy, even if the client submits a superbill. Reimbursement depends on the specific plan’s out-of-network benefits, which can vary widely. Some plans may cover a portion of the cost after the client meets their out-of-network deductible, while others may not offer any out-of-network coverage at all. It’s essential for clients to verify their benefits directly with their insurance provider before starting therapy, so they understand what documentation is required and what level of reimbursement, if any, they can expect.