Initial Assessment

Every client (individual, couple or family) receiving treatment at Rula, must have an Initial Assessment (CPT 90791) completed during the first visit. The Initial Assessment serves as the foundation for identifying treatment needs, establishing a diagnosis and determining therapeutic fit. This article reviews the clinical information you will collect in the Initial Assessment Template and includes a FAQ section.

 

Initial Assessment Details

Before beginning this session, it is advisable to first orient the client to the clinical purpose of the initial assessment. This sets expectations for the session, the information to be obtained, and supports the client in understanding the “why” of the assessment, before actual therapy can begin. 

  • “I am so glad you are here. Our goal for today is to ensure I have a good understanding of what is bringing you to therapy, and how I can support you in meeting your treatment goals, before we start the therapy process. I’m going to ask you a variety of questions which will help us do this.”  

Then you will collaboratively work your way through the Initial Assessment template, which collects valuable clinical information on the following:

  • Presenting problem - What brings the client to seek mental health treatment? You will want to identify why the client is seeking treatment at this time, including onset, duration and severity of symptoms. To support medical necessity for services, it is important that this section includes specific clinical information related to the client’s mental health symptoms (For example, instead of just writing “Client has anxiety,” you should be more specific as to which DSM-5-TR criteria the client experiences to justify a diagnosis of anxiety, such as chronic worry, intrusive thoughts, difficulty focusing) as well as how these mental health symptoms are impairing the client's functioning, such as increased isolation, loss of relationships, and decreased performance at work. 
  • Health history (Medical conditions, current medications) 
  • Psychosocial (Interpersonal/family relationships, Education, Employment, Living situation, Trauma or abuse history)
  • Cultural Considerations - A culturally responsive approach to care includes recognizing how culture can affect help seeking behavior, manifestation of symptoms and selection of effective interventions. “Culture” can include a variety of considerations such as ethnicity/race, age, sexual orientation, gender identity, values/beliefs, language, socioeconomic status, family dynamics, and/ or religious/spiritual identities. Answers such as “N/A or None” in this field are flagged.
  • Substance Use history
  • Mental Health Treatment history
  • Population specific questions (i.e questions specific to couples, families or child/adolescent clients) 
  • Risk Assessment - This section needs to be completed regardless of whether or not the client has a presenting problem related to risk.
  • MSE (Mental Status Exam) 
  • Clinical Summary - summarizes the presenting problem, symptoms, diagnosis, functional impairments and justification for services. This is not a repeat or copy/paste of the presenting problem and should clearly identify the need for treatment and the justification of a diagnosis.
  • Diagnosis
  • Initial Treatment Plan 

Initial Assessments also offer a space for clients to ask any questions that they may have about the therapeutic process, cancelation policies, billing and payment, scheduling availability etc. 

 

Initial Assessment FAQ

  • How long should an Initial Assessment take? The average session lasts 60 minutes, but not all your assessments will fit into this timeframe, especially if conversations with family members are involved. It’s important to note that the CPT code for an Initial Assessment (90791) requires that the assessment last a minimum of 16 minutes, and can be billed up to a maximum of 90 minutes in order to receive reimbursement. You may not schedule (or bill for) an additional initial assessment with the same client in order to finish the initial assessment due to time constraints. 

  • If the client is a minor, can I complete an Initial Assessment with only the parent/guardian present (no client) since they have most of the historical information anyways? Rula requires the consenting parent/guardian to present at the first appointment with a minor under 13, and it is recommended that a parent be present for the first visit with adolescents ages 13-17. However, while family members should be involved, the primary client (in this case, the minor)  must also be present for at least a portion of the session. This is because some required elements of the Initial Assessment such as the MSE require you to assess the actual client, not a family member.

  • Do I have to fill out every field in the Initial Assessment note template? Any field that is yellow is required to complete, as they have been mandated by our insurance payors and are necessary for reimbursement. You will not be able to sign the Initial Assessment without completing these fields.

  • How does the Initial Assessment for Couples or Families differ from the initial assessment for individuals? There is a different template for the Initial Assessment & Treatment Plan for Couples and Families which features additional tabs and sections to support care for couples or families. Any time a couple or a family is in treatment, one individual is identified as the Primary Patient. This individual’s medical chart is where you will document care, and the Diagnosis and billing information will be submitted for the primary patient. Rula only requires a diagnosis for the Primary Patient. 

  • What if I am not able to determine an official diagnosis during the Initial Assessment, but I do think the client needs treatment?  It’s not uncommon to need some additional time to further evaluate a client's symptoms and engage in a differential diagnosis process, however you cannot sign the note (and bill for the services) if you don't list a covered diagnosis. In these cases, it is advisable to consider if use of an interim “unspecified” diagnosis may be clinically indicated until you can confirm something more precise. You also may use “F99 - Mental disorder, not otherwise specified” for 1-2 sessions while you further confirm the diagnosis. 

  • What if the client and I don’t have enough time to create a Treatment Plan during the Initial Assessment? A treatment plan is a required component of the Initial Assessment in order to be able to sign and bill for the appointment. While the aim should always be to set some preliminary treatment goals and objectives during this first encounter, if you run out of time you may enter a preliminary goal  such as “Establish therapeutic rapport,” or “increase understanding of mental health needs,”  The first psychotherapy session should then have a primary focus of clarifying the treatment plan so the therapist and client are in agreement of client goals, objectives and treatment approaches for care before moving forward. 

  • A client was rematched to me after working with a different therapist at Rula, do I need to complete a new Initial assessment? Yes, it is best practice to complete a new Initial Assessment at the onset of care with any new client, even if they recently completed one with a different therapist. This is because the assessment of symptoms, diagnosis, and treatment needs should always be based on your own evaluation and assessment skills and not the previous evaluation of another therapist, whose assessment and conceptualization of care needs may differ from yours. It also can breed risk, negatively impact care, and prevent referrals from HLOC from being processed if you have not completed the full initial assessment with a client yourself to understand and determine treatment needs, as well as your ability to meet those, prior to providing therapy.

  • Can I see examples of completed Initial Assessments? You got it! Click HERE


If you have questions or support needs related to initial assessments,  reach out to our clinical quality team at quality@rula.com
. Therapist to therapist - we’re here for you!

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