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Documentation and Treatment Planning: The Ins and Outs Of Maintaining a Client Case File

CE Hours 1

About this course

This comprehensive course provides therapists with the knowledge and practical skills to create clear, accurate, and compliant clinical documentation that reflects the quality and necessity of care. Designed for therapists and counselors, this course explores the essential components of documentation that meet regulatory standards- including medical necessity, treatment planning, intakes, and progress notes. Participants will learn how to articulate clinical reasoning, and justify services for reimbursement. Therapists will gain confidence in writing documentation that is defensible, efficient, and patient-centered.

Learning Objectives

  • Develop an understanding of the importance of maintaining proper documentation for client files, as well as the implications for insufficient documentation
  • Learn what specific information must be included in an intake note, progress note, and treatment plan
  • Documentation differences between in-person visits vs telehealth sessions

Learning Levels

  • Beginner

Course Instructor(s)

  • Leanda Zupka, LCSW

    Leanda Zupka is a Licensed Clinical Social Worker in the State of Connecticut, located in the Northeast “quiet” corner of the state.

    With more than 15 years of clinical experience in private practice, Leanda provides individual therapy for adults coping with anxiety, depression, infertility/IVF/surrogacy, and life transitions. Prior to establishing her own practice, her previous experiences focused on youth and adolescents in crisis and in residential treatment. In addition to a full time private practice, Leanda collaborates with colleagues, offering clinical supervision to both provisionally and fully licensed clinicians. She also provides consultation and training on clinical documentation.

Disclosure

This is an NBCC approved CE Event and is not NASW or APA approved. Confirm with your state licensing board if this course meets your continuing education requirements, depending on your clinical license type.

CE Process Info

Content

  • Materials
    1 parts
    • Progress Note Checklist
  • Recordings
    1 parts
    • Video recording
  • National Board for Certified Counselors (NBCC)

    Tava has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7563. Programs that do not qualify for NBCC credit are clearly identified. Tava is solely responsible for all aspects of the programs.

FAQs

  • Course Completion
    To complete the course, review the course objectives, then watch the video power point presentations, and lastly complete an evaluation. Your certificate will be available to download immediately when you complete the evaluation. Note that you can not continue in the course until you complete the previous section.
Documentation and Treatment Planning: The Ins and Outs  Of Maintaining a Client Case File
You Have Completed This course
Free
You are enrolled
  • CE Hours
    1
  • Type
    Self-Paced
  • Publication Date
    Jan 23rd, 2026

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