Couple or Family Charts

Clinicians who engage in Couple or Family therapy can handle couples therapy in two ways.

Option 1 includes a single patient chart, note, and billing for the primary partner or family member only, whereas option 2 includes a patient chart, note, and billing for both partners or family members.

👤 Option 1

Create a client chart, schedule, complete notes, and bill for the primary partner / family member only. 

  1. Create a "primary" client
    Decide which person in the couple serves as the primary patient.  (You could have them flip a coin). If you are not billing insurance, the patient first name could be ‘John and Mary’ and the patient last name could be ‘Jones’ or ‘Jones and Johnson” If you ARE billing insurance, the name entered must be the name of the identified patient. The ‘nick name’ on the profile could be ‘Mary and John’ or ‘Family’
  2. Schedule Appointment
    Schedule the patient on your schedule as you would any client.
  3. Notes
    Complete the note that corresponds with the scheduled appointment. It is recommended that in the note narrative, you include information about who was in attendance at the appointment that day.
  4. Billing
    Once the appointment is concluded and you have either accepted payment or started a note, the client account will be billed for the service accordingly.

👥 Option 2

Create clients, group, schedule, complete notes, and bill both partners or family members, or just one (and mark the other as yes/attended & no fee).

  1. Add each member as an individual client 
  2. Then create and name the group something appropriate such as ‘Smith Family’. 
    This group name only has to be meaningful to you – not to the client. Now assign each member of the family to the group. Set up the default CPT code that you will be charging for the service.
    For additional information on setting up and charting on groups, please click here.
  3. Scheduling Appointments 
    Schedule the couple/family appointment by going to your schedule, clicking on the timeslot, and entering the group name.
  4. Notes
    Complete the corresponding group therapy progress note for each member of the family. Be sure to document the parties names who were in the counseling session.
  5. Billing
    When checking in the client, there are two sections: Yes/attended, and no/did not attend.
    In this example you can:
    • Set one to yes/attended with the billable CPT code
    • Set the other to yes/attended with no fee (so you can still chart on them)

Example:

Things to Think About:

From the perspective of a Marriage and Family Therapist on this topic:

clinical_notes From Denise Hoyt, LMFT :

If I were keeping a paper record on a couple or a family, I would have ‘one folder’ to hold all of the notes, because the ‘couple’ or the ‘family’ is my client – not the individual member of the party. Also, I am ethically bound to NOT release any couple or family records without written consent of ALL parties involved. By using Option 1, I am reasonably protecting myself if there is a request to release records, because it’s obvious this was a couple/family session. By using option 2, it means that if I’m not careful and there’s a record request by an individual in that family, that I may not realize that there are other parties involved in the session, and if I released records, I could be breaching my professional ethics and state laws.