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Therapy Notes: How to Document Gray Areas

By Maelisa Hall

Therapy Notes Documentation with Maelisa Hall, PhD

Not every therapy client is high-risk or worry-free—most fall somewhere in between. These “medium risk” situations include ongoing depression, self-harm behaviors without suicidal intent, impulsivity, and substance use. They require consistent assessment but don’t typically warrant hospitalization. The challenge? Knowing what to document and how often. This guide provides five practical tips from clinical documentation expert Maelisa Hall for managing therapy notes with medium risk clients. You’ll learn how to identify what’s truly relevant to document (without writing excessive notes), see a real DAP note example for a client with moderate depression, and discover why reviewing your documentation monthly can transform your practice. Whether you’re a new clinician or experienced therapist, these strategies help you create meaningful, legally sound therapy notes without burning out on paperwork

Filed Under: Clinical Practice, Expert Interviews, Therapeutic Skills Tagged With: documentation, Maelisa Hall Psy.D., suicidal ideation, suicide, suicide prevention, therapy notes

Suicidal Ideation: How to Document

By Maelisa Hall

4 suicidal ideation notetaking tips

When a client expresses suicidal ideation, documentation becomes crucial but also anxiety-inducing for many clinicians. Learn the four key components of effective suicide risk assessment documentation: providing clear client data with exact quotes, identifying risk and protective factors, creating safety plans (not contracts), and explaining your clinical rationale. This guide includes a sample progress note using the DAP format and best practices for follow-up documentation. Whether you’re a new clinician or experienced practitioner, these principles will help you create ethically sound documentation that protects both you and your clients while improving clinical practice.

Filed Under: Clinical Practice, Expert Interviews, Featured Expert Interviews, Therapeutic Skills Tagged With: documentation, Maelisa Hall Psy.D., suicidal ideation, suicide, suicide prevention, therapy notes

Suicide Prevention: Take Five – You’re Worth It!

By Dorlee

Take Five – You’re Worth It! To those of you who feel utterly hopeless, Overwhelmed, think there is no way out, Or see nothing to look forward to, I ask you to take a few minutes, To consider another possible solution, Than that of ending your life… There are people who love you, There are […]

Filed Under: Motivational, Personal Growth, Self Care, Social Work, Therapy Tagged With: suicide prevention

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