I’ve included a list of questions/topics we explore as a biopsychosocial exploration in the very first session with a client. This also includes the housekeeping topics we explore at the beginning of the first session. I have these added as a chart note template on Jane which I’ll show you later. This will help you prepare for the types of things you will be discussing in your first session with clients.

First Session Biopsychosocial Questions

Housekeeping

1) Confirm the client has signed the consent form & completed credit card authorization form if they wish to pay via credit card.

2) Review the consent form with the client and ensure the consent obtained was INFORMED.

3) Review limitations surrounding internet and audio/visual calls on Jane practice management software.

4) Explain the process of note-taking.

5) Termination discussion - what to expect.

6) Discuss Cancellation policy

6) Conflict of interest & Dual Relationship

7) Discuss payment, confirm payment method. If a client is late on a payment or misses a payment, our policy is that we require a credit card on file after the first instance of this happening. This ensures that clinicians aren't spending all their time chasing down clients for payment. If a client is ever late on a payment or doesn't pay, you can reference the consent form they have signed and require a credit card from them before proceeding with services.. 

** Note, make sure that you client has signed the 2023 consent forms as these have the new policy regarding credit card requirements! ** 

8) Client Agreed to a payment fee of : _______

8) Ask client if they have any questions before moving forward.

o   Do you have any questions?

o   Describe first Session is information gathering – extension off of intake.

Personal Background

o    Family of Origin

o    Personal Identity (Gender, Sexuality, Cultural,Religious etc) *Reminder to ask consent, answers are never required!*

o    Extended Family

o    Social Norms of Family

o    Rules of the family  & Social Norms

o    Growing Up – childhood, middle school, high school

o    Post secondary school/career path?

o    Work life

o    Meeting partner (husband/wife/kids)

o    Social Network: Friends, socializing, Partner(s)

Habits

o    Hobbies – Self care activities, activities you enjoy, interests

o    Habits - Caffeine, Alcohol, Drug & Weed Habits, food, sleep if any

o    What does any average day look like?

Presenting Problem

o    Diagnoses & meds?

o    What does it look like?

o    Explain symptoms

o    Triggers

o    Examples of experiences

o    Thought process

Themes

Any themes you’ve identified throughout this session?

Closing Up

o    Goals for Therapy

o    Overarching Plan for therapy

o    Homework for this week – recording, journaling, writing down thoughts and experiences related to the presenting problem

o    Opening can of worms- normalizing the first session, promise to ‘give more’ next session

o    Payment Options- if not done.

o    Rebook following session.

Plan/Homework

Did you assign any tasks for them to complete in between sessions? Did you set a plan for therapy?

Thoughts for future sessions

Therapist use - do you have any thoughts for next session?