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

CE Hours 1

About this live event

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

Agenda

1. Importance of Clinical Documentation
Understanding why accurate, complete documentation is essential for clinical care, legal compliance, and insurance requirements.

2. Intake Documentation Requirements
Overview of required components including presenting concerns, history, mental status exam, diagnosis, and billing elements.

3. Progress Notes & Medical Necessity
How to write compliant progress notes using SOAP format, document medical necessity, and align content with diagnoses.

4. Telehealth Documentation Standards
Specific requirements for telehealth sessions, including location, consent, platform requirements, and safety information.

5. Treatment Planning & SMART Goals
How to create and revise treatment plans, develop measurable goals, and ensure alignment with client diagnoses.

6. Examples & Application
Walk-through of sample notes, goals, and interventions illustrating best practices and common pitfalls.

Live event 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

Before the event, you will receive an email from CE-Go with access to the virtual event. After the event, you will receive access to your evaluation and continuing education certificate via a personalized "attendee dashboard" link, hosted on the CE-Go website. This link and access to the virtual event will be sent to the email account you used to register for the event.

Upon accessing the CE-Go "attendee dashboard", you will be able to:

  • Complete evaluation forms for the event
  • Download your continuing education certificate in a PDF format

If you have any questions or concerns regarding the CE-Go platform, please contact CE-Go at 888-498-5578 or by email at support@ce-go.com Please Note: Emails for this event will come from "support@ce-go.com".

If you have any continuing education related questions, please contact your event organizer at therapist-support@tavahealth.com. 

Please make sure to check your spam/junk folder in case those emails get "stuck". We'd also suggest "Allowlisting" support@ce-go.com. This tells your email client that you know this sender and trust them, which will keep emails from this contact at the top of your inbox and out of the junk folder.

  • 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.

Technology

1. This virtual event will be hosted via Zoom Webinar, and you may be prompted to download or upgrade your Zoom app if using a mobile device. A strong WiFi connection will be required for best quality.


2. We recommend clicking your "Join Webinar" button early and checking that your speakers are on before the event begins. Please do not worry about being seen or heard! Attendee video feeds and mics are turned off by default when entering a webinar. You will be able to ask questions via the Q&A feature.


3. Please respect that no copying, recording, or distribution of live session content is allowed. CE's are provided for the "live" sessions only.

Where can I find my Attendee Dashboard link?

Upon registering, you should receive an email from support@ceactivities.com with a link to access your Attendee Dashboard. If you do not see it in your inbox, please check your spam/junk folder. If you still cannot locate the email, you may retrieve your Attendee Dashboard link by clicking HERE

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Documentation and Treatment Planning: The Ins and Outs Of Maintaining a Client Case File
You Have Completed This course
Free
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  • CE Hours
    1
  • Type
    Live Interactive Webinar
  • Date
    Thu Jan 15th, 2026
  • Time
    12:00pm - 01:00pm EST

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