If a client has a name that differs from their legal name you should discuss with them how they would like their name to appear in their documentation. Give consideration to the potential future release of documents to SDMs, lawyers, other providers, caregivers, etc. All records will still contain the client’s legal name at the top of the form.

Generally, you should not create or start a form prior to an event occurring. This helps to prevent the duplication and presence of empty forms in the client file.