Step‑by‑Step Workflow for Seeing Couples at Rula

Working with couples can be deeply rewarding—and clinically complex. At Rula, couples therapy typically occurs within an insurance framework that is centered on one identified client. This article offers a practical, step‑by‑step workflow and checklist to help you structure care, protect the therapeutic relationship, and meet documentation and quality expectations.

1. Before You Begin: Clarify the Identified (Primary) Client

In insurance-funded couples therapy, one partner must be the identified client (primary patient). All billing, diagnosis, treatment planning, and MIC measures are anchored to this person.

Key steps:

1. Confirm who the primary patient is (the person whose Rula chart you are using).
2. Clearly explain this to the couple as an insurance/structural requirement—not a judgment about who is “the problem.”
3. Set expectations that:
   • Documentation will be framed through the primary patient’s diagnosis, symptoms, and functioning.
   • The work still supports both partners and the relationship.

2. Gather Demographic Information for the Secondary Partner

Because the EHR is built for individual care, you will not have a full chart for the non‑identified patient. To support safety and coordination, use the Secondary Partner Intake Demographic Form. This form gathers information for the secondary partner such as: 

• Full name
• Date of birth
• Phone number and/or email
• Physical address
• Previous therapy experience
• Health/Medication information
• Emergency contact.

• Upload this completed form into the patient’s chart and document a blank note with any additional details. 

3. Complete the Couples Therapy:
Agreement & Informed Consent

Provider steps:

1. Review and complete the Agreement & Informed Consent with both partners in session.
2. Ensure they understand:
   • Who the legal “patient” is for documentation and records access.
   • How confidentiality works and its limits in a couples context.
   • How records may be used or requested in the future (e.g., legal proceedings, insurance, etc.).
3. Document in your note that the Agreement & Informed Consent was reviewed and completed.
4. Upload the completed Agreement & Informed Consent into the primary patient’s record.  

4. Consider Additional Practice Policies

In addition to Rula’s standard informed consent, consider whether you want to implement additional guidelines or policies, either verbally or in writing. This will be based on your own clinical modality and judgment. 

Topics to consider:

• Contraindications for couples therapy, such as:
  • Active intimate partner violence (IPV) or coercive control
  • Active substance use disorder that is not being treated
  • Active infidelity that has not been disclosed
  • Severe, untreated mental health conditions that compromise safety or engagement
• No‑secrets or limited‑secrets policy:
  • Will you keep individual disclosures confidential?
  • Under what circumstances (if any) will you share information disclosed privately with the partner?
• Couples therapy in an insurance environment:
  • One partner is the identified client.
  • Documentation and diagnosis are tied to that primary patient.
  • Relationship distress can be reflected using Z‑codes, but cannot serve as the primary/billing diagnosis.
• Your own couples‑specific practice policies, for example:
  • Whether you will hold individual sessions with either (or both) partners and how those are billed (e.g., 90846).
  • How you handle situations in which couples work becomes contraindicated and a higher level of care or separate individual therapy is recommended.

Document in your intake note that these topics were discussed and that the couple had an opportunity to ask questions.

5. Conduct the Initial Assessment

Your initial assessment must still meet all individual assessment and documentation requirements for the primary patient, while reflecting the relationship context and clearly identifying how couples therapy can be helpful to the clinical needs of the primary patient.

Assessment focus:

1. Primary diagnosis for the identified client:
   • Assess symptoms, onset, duration, and severity.
   • Clearly document functional impairment (work, relationships, ADLs, etc.).
2. Link relationship problems back to the primary diagnosis.
   • Describe how relationship distress exacerbates or maintains the primary patient’s symptoms.
   • Example:
     • Primary Dx: F41.1 Generalized Anxiety Disorder
     • Clinical narrative: “Client reports chronic worry and somatic anxiety symptoms that significantly worsen in response to frequent, escalating arguments with partner, particularly when communication becomes verbally explosive.”
3. Use Z‑codes to capture relationship problems, secondary to the primary clinical F-code diagnosis (optional but recommended).
   • You may add an appropriate Z‑code (e.g., Z63.x) to reflect:
     • Relationship distress between spouses or partners.
     • Family conflict or other relational problems.
   • Important:
     • Z‑codes cannot be the primary or billing diagnosis.
     • They can be listed as secondary codes to clarify clinical context.
4. Screen for contraindications to couples therapy.
   • Explore:
     • IPV/domestic violence.
     • Fear, coercion, or control.
     • Active addiction or untreated severe mental illness.
   • If any red flags are present, pause and consider whether couples work is appropriate or whether a higher level of care, individual work, or referral is indicated.

6. Build a Couples‑Informed Treatment Plan

The treatment plan must:

• Be measurable.
• Clearly link back to the primary patient’s diagnosis and symptoms.
• Show how couples therapy is expected to improve the primary patient’s functioning.

Treatment planning checklist:

1. Identify the client’s own words for what they want.
   • Example: “I want to stop feeling so anxious and walking on eggshells in my relationship.”
2. Translate into a clinical goal connected to diagnosis.
   • Example goal:
     • “Reduce anxiety symptoms associated with high‑conflict communication patterns in the relationship.”
3. Add specific, measurable objectives that involve couples work:
   • Example (for GAD with conflictual communication):
     • Objective 1: “Client and partner will learn and practice a mutually agreed‑upon communication structure (e.g., speaker–listener) in session and report using it at home at least 2 times per week over the next 4 weeks.”
     • Objective 2: “Client will report a decrease in frequency of ‘explosive’ arguments from 4x/week to 1x/week or less over 8 weeks, as measured by self‑report.”
     • Objective 3: “Client’s GAD‑7 score will decrease by at least 5 points over 12 weeks, indicating clinically meaningful reduction in anxiety.”
4. Make the “Golden Loop” explicit:
   • Diagnosis → Symptoms → Functional impairment → Treatment goals → Session interventions (couples‑based) → Documented progress.
5. Example goal structure:

7. Use MIC With Couples

Measurement‑Informed Care (MIC) is a clinical quality requirement at Rula.

For couples therapy:

• One member of the couple—the primary patient—must complete MIC measures.
  • These should be reviewed regularly and integrated into your clinical formulation and progress notes.
• At this time, we do not have couples‑specific MIC measures. You will use the standard individual measures (e.g., PHQ‑9, GAD‑7, TA, etc.) with the primary patient.
• In your notes, document:
  • That MIC data was reviewed.
  • How scores relate to relationship stress.
  • How you are using MIC results to adapt couples interventions (e.g., focusing more on de‑escalation skills when scores worsen around conflict).

Couples‑specific measures may be added in the future; for now, continue anchoring MIC to the primary patient.

8. Access Individual Notes: Ethical and Clinical Considerations

At Rula, you may have access to other providers’ notes if:

• Your primary patient already has an individual therapist or psych prescriber at Rula, and,
• You are now providing couples therapy with the same patient who was identified as the client.

Best practice recommendation:

• It is generally recommended not to review individual therapy or psychiatry notes for your couples cases, even when you technically have access.
  • If you would like to review notes, it is best practice to verbally disclose this with the patient and gain their verbal agreement. If they do not agree, it is worth exploring this hesitation together. 
• If you do review notes for one member, ask yourself:
  •  Should you also request/read the other partner’s individual notes (if they also have Rula providers) to avoid bias?
  • Example scenario:
    • If you read an individual note disclosing an undisclosed affair, could you remain neutral and non‑biased in couples sessions if the affair has not been brought into the room?
• If you decide it is clinically necessary to review notes:
  • Consider carefully how this will impact:
    • Your neutrality.
    • The therapeutic alliance with both partners.
    • Your ability to manage secrets and disclosures ethically.
  • Document your clinical rationale in a neutral, concise way.

When in doubt, seek consultation before accessing collateral notes for couples' cases.

9. Ongoing Sessions: Documentation and Focus

For each couples’ session:

In your progress note, ensure you include:

• Medical necessity clearly anchored to the primary patient’s:
  • Diagnosis and symptoms.
  • Functional impairment.
  • How the relationship dynamics affect those symptoms.
• Couples‑focused interventions, such as:
  • Communication skills training.
  • Emotion regulation/co‑regulation strategies.
  • Conflict de‑escalation and repair attempts.
  • Attachment‑focused or systemic formulations.
• Client response, including:
  • How the primary patient is responding and any observable shifts in anxiety, mood, or functioning.
• Progress toward treatment plan goals, explicitly tied back to:
  • Symptom reduction,
  • Improvement in functioning, and
  • Changes in relational patterns (e.g., fewer explosive arguments, more successful repair attempts).
• Plan, including:
  • Homework or practice tasks for the couple between sessions.
  • Any safety considerations or referrals if needed.

Remember: Document through the lens of the identified client, even while you are working with the couple system.

10. Use Available Supports: Guidelines & Case Consultation

You are not alone in navigating couples work at Rula.

Resources:

• Couples Clinical Care Guideline
  • Please review the Couples Clinical Care Guideline for more detailed best practices, contraindications, and assessment considerations.
• Couples Case Consultation Group
  • Rula offers a couples case consultation and clinical support group for therapists who work with couples (including monogamous, polyamorous, LGBTQIA+, and other non‑traditional partnerships).
• Provider Community
  • We encourage you to join our Provider Community, specifically our Relationship Therapy Roundtable. This is a great place to ask questions to other therapists at Rula who work with couples!

Quick Reference Checklist

Use the checklist below as a quick reference.

Updated May 20, 2026 19:47