Documentation
nExclude
nInformation that can
easily be misinterpreted
nInformation that has no
impact or is irrelevant to Dx or Tx
nPast criminal behavior
if not relevant to Tx or risk
nSexual behavior if not
relevant to Tx or risk
nYour personal comments,
opinions or process notes
nRemarks about 3rd parties unless important to Tx
nClient writings and
journals