The first session is an opportunity to help clients identify their concerns and develop a treatment plan to guide the therapeutic process.

Billing & CPT Code

• Use CPT code 90791 for initial visits.
• Compensation is not based on session length, but sessions must be at least 16 minutes to qualify for reimbursement.

Recommended First Session Documentation

To ensure comprehensive documentation, we recommend using this treatment plan template for your first visit with a new client.

1. Presenting Challenge

Document the client's reason for seeking therapy, including:

• Primary signs and symptoms
• Frequency, duration, severity, and cycling of symptoms
• History of the presenting concern
• Barriers affecting progress
• Strengths and protective factors

Example:
"Client is presenting for therapy due to experiencing decreased interest in typically pleasurable activities and increased fatigue."

2. Mental Status Exam (MSE)

Assess the client’s current mental status using the following criteria:

• Appearance/Dress/Grooming
• Affect/Mood
• Thought Process/Orientation/Attention/Memory
• Functioning/Behavior

Example:
"Client presented for the first session today via video. The client appeared to engage in normative affect and behavior, as demonstrated by consistent focus, goal-oriented narrative, and active participation."

3. Biopsychosocial Assessment

Evaluate biological, psychological, and social factors contributing to the presenting concern.

Biological Factors

• Physical health and medical history
• Substance use history (if applicable)
• Family mental health history
• Demographic identities (age, race, gender, sexual orientation, etc.)

Example:
"Client reports a history of heart disease and type 2 diabetes, which is historically present in maternal family history."

Psychological Factors

• Prior therapy or counseling experience
• Mental health diagnoses & medication history
• Current medications, supplements, vitamins

Example:
"Client identifies this as their first counseling experience but reports being diagnosed with ADHD by their primary care physician in elementary school."

Social Factors

• Family & significant relationships
• Childhood & adolescent history
• Employment & education
• Cultural, ethnic, spiritual, or religious background
• Leisure & recreational activities

Example:
"Client is employed part-time and enjoys biking with their partner on weekends."

4. Treatment Plan

Develop short- and long-term objectives, interventions, and follow-up plans to address client concerns.

S.M.A.R.T. Goals

• Specific: What will be accomplished?
• Measurable: How will progress be tracked?
• Achievable: Is the goal realistic?
• Relevant: How does this goal align with therapy objectives?
• Time-bound: What is the timeframe?

Example:
"Client will practice 1 self-directed mindfulness activity each day for 5 minutes over 60 consecutive days to increase confidence in utilizing the skill."

Interventions & Modalities

• Therapeutic approaches (CBT, EMDR, Narrative Therapy, etc.)
• Techniques (Reflective listening, empty chair, behavior modeling, progressive muscle relaxation, etc.)

Session Frequency & Plan

• Weekly, bi-weekly, monthly, etc.

Example:
"Client will increase social support over the next 6 months by attending therapy weekly, reaching out to an identified social support bi-weekly, and participating in one local community event monthly."