The documentation of clinical services has taken on unprecedented importance for practicing psychologists. Structuring quality care, decreasing liability exposure, and fulfilling requirements for reimbursement are primary objectives in pursuing thorough documentation practices. As a practice aid and a brief reminder, the authors review the basic structure for documenting an initial evaluation, highlighting content areas that are felt to be important for attaining the objectives noted above. The authors suggest that psychologists use the term psychological consultation to specify this procedure, designating it as a distinct process from psychological testing or psychological treatment.
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