CLINICAL THERAPIST – LMSW

CLINICAL THERAPIST – LMSW

The Clinical Primary Therapist works with clients, either individually or in groups, to address mental health concerns. The Clinical Primary Therapist applies knowledge and skill to assist clients in recovery and illness management. The Primary Therapist is responsible to establish the boundaries of therapy including a comfortable safe environment, caring therapeutic culture and foundation for client / family engagement in recovery and behavioral management. The Primary Therapist completes a comprehensive assessment gathering data and information resulting in clinical formulation as the framework for development of the treatment plan. In collaboration with the client / family the Therapist establishes goals for treatment and identifies the interventions to promote goal achievement. The Clinical Primary Therapist is responsible for timely accurate documentation in the client’s medical record, coordination of care with colleagues in the clinic and colleagues throughout the continuum to secure the appropriate treatment resources to promote client health. The Primary Clinical Primary Therapist participates in the on call rotation to the Emergency Departments to provide mental health crisis evaluations

Comprehensive assessment, includes the psychosocial history, lethality (risk of harm to self or others), behavioral observations, substance dependence /abuse, the client’s chief complaint, focus/goals of needed treatment, physical, developmental, cognitive, mental and emotional health status, demographic profiles, history of health patterns, illnesses, past history and treatments, and family, social, cultural, community supports and strengths that can be used to promote health. Assessment includes screening for co-occurring substance use disorder. The assessment results in a clinical formulation which informs the treatment plan Reassessment of behaviors is completed at each visit.

Diagnosis and potential problem statements are derived from assessment data. Diagnosis and risk factors are discussed with the patient and family. Treatment plan are person centered, recovery oriented and responsive to cultural and linguistic needs of the client. Treatment plan goals/objectives are clearly linked to the assessment and discharge criteria, are individualized and person centered.. Treatment plans reflect attainable steps toward goal achievement and include target dates, contain specific evidence based interventions/services used by the therapist and identifies frequency of services. Treatment plans are developed signed by client and therapist within 30 days of admission. Discharge criteria are identified within the treatment plan, updates and reflect the desired accomplishments of the client.

Completes and maintains clinic records and progress notes according to regulations and within specified timeframes. Progress notes are linked to goals/objectives and summarize services provided, interventions utilized and clients response and progress toward goals. New information impacting treatment is incorporated in the documentation and considered in the treatment plan updates. Evidence of engagement and retention is reflected in the documentation t. Discharge criteria are developed and documents expected change in patient status

Evidenced based interventions reinforce healthy behaviors and interactions. Counseling promotes the patient’s personal and social integration and includes health education in the areas of increased coping, medication use, social skills, and symptom management

Systematically evaluates quality and effectiveness of Therapy Practice both individual and group, and uses the results of quality improvement activities as well as evidence based interventions to initiate changes in individual therapy practice and to influence delivery of mental health services within the clinic. Engages in self-evaluation of practice, identifying strengths and areas in which professional development would be beneficial and takes accountability / initiative to increase knowledge and enhance skill. Collaborates with members of the clinic team to achieve productivity standards, reduce no show rates and facilitate client engagement.