Why You'll Love This Course

Many of us had initial training in documentation that lacked essential elements. This course offers key knowledge about documenting mental health care without judgment or criticism for however you may have initially learned the process. The course is clear, supportive, and useful, particularly in its discussion of avoiding common mistakes.

Course Description

This course provides foundational instruction on documentation in mental health care. Topics include legal and ethical requirements for documentation, common components of client files, and avoiding common documentation mistakes. 

1 Hour CE. Recorded Video Format (non-interactive).

Learning Objectives

By the end of this workshop, participants will be able to:

  • Identify at least five common components of a clinical file.

  • Identify at least three common components of strong clinical documentation.

  • Identify at least three common mistakes clinicians make in documenting client services.

Course Outline

1. Introduction

2. Legal and Ethical Context 

3. Typical Components

4. General Principles

5. Common Mistakes


Benjamin Caldwell, PsyD, LMFT

Education Director, SimplePractice Learning

Benjamin Caldwell, PsyD is a California Licensed Marriage and Family Therapist (#42723). He currently serves as adjunct faculty for California State University Northridge in Los Angeles. He has taught at the graduate level for more than 15 years, primarily in Law and Ethics, and has written and trained extensively on ethical applications in mental health care. In addition to serving a three-year term on the AAMFT Ethics Committee, Dr. Caldwell served as the Chair of the Legislative and Advocacy Committee for AAMFT-California for 10 years. He served as Editor for the Users Guide to the 2015 AAMFT Code of Ethics and is the author of several books, including Saving Psychotherapy and Basics of California Law for LMFTs, LPCCs, and LCSWs.

In his teaching and books, Dr. Caldwell discusses legal, ethical, and practical considerations in the documentation of mental health care.

User Reviews

Excellent! I highly recommend for all clinicians

Sara Silvia

A lot of important information was covered concisely and effectively. It was a very effective primer. It is giving me cause to reflect on my current practices. I will use what I learned and implement immediately.

A lot of important information was covered concisely and effectively. It was a very effective primer. It is giving me cause to reflect on my current practices. I will use what I learned and implement immediately.

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Solid content

Debbie Stanley

I found this course more substantive than typical 1-credit CEUs.

I found this course more substantive than typical 1-credit CEUs.

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Awesome Presentation

Andrea Levitan

Enjoyed the content!

Enjoyed the content!

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Excellent and very clear

Katherine Jupp

Additional Information

Format and Length:

Recorded Video Format (non-interactive); Total running time 64 minutes

Instructional Level:


NAADAC Counselor Skill Group 5: Documentation

Completion Requirements:

To obtain your CE certificate, you must progress through all course segments, complete a satisfaction survey, and obtain a score of 80% or higher on a course completion quiz.

Who Should Attend:

Counselors, clinical social workers, marriage and family therapists, and substance abuse counselors.

Enrollment Period: 

90 Days

Publication and Review Dates:

Course Published: December 05, 2018 

Financial Support Statement:

SimplePractice Learning pays course presenters for their teaching. There is no other financial support for this course.

Conflict of Interest Statement:

There is no potential conflict of interest or outside commercial support for this course.

Refund Policy:

Click here to see our policies on attendance, refunds, grievances, and accessibility, and other frequently asked questions.

Continuing Education Approvals:

This course is not part of our APA-approved continuing education program for psychologists at this time.

SimplePractice has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6961. Programs that do not qualify for NBCC credit are clearly identified. SimplePractice is solely responsible for all aspects of the programs.

SimplePractice is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #145276). SimplePractice maintains responsibility for this program and its content. This course meets the qualifications for 1 hour of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. 

SimplePractice is approved as a Rule/Statute Approved Provider of Continuing Education by the Florida Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling. Note that we do not automatically report CE completion to CE Broker at this time, so certificates of completion must be manually uploaded. Click here for more information.

SimplePractice is approved to provide continuing education activities for Social Workers in the state of Texas. Social Work CE Provider Number 7678.

This course has been approved by SimplePractice, as a NAADAC Approved Education Provider, for 1 Hour CE. NAADAC Provider #186410. SimplePractice is responsible for all aspects of their programming. Click here to view our complete CE approval information.

This course is not part of our continuing education program as an approved provider for the New York State Education Department's State Board for Social Work.