Kaerensa Craft, LCSW, PSYCHOTHERAPY

NY, NY | Montclair, NJ

CONFIDENTIALITY AND RECORDS

 

CONFIDENTIALITY AND RECORDS

Your records, as well as what we discuss in treatment, are confidential, meaning that I alone have access to them, although there are some limitations to this:

Indication of Risk of Harm

If you give me reason to believe that you are presenting imminent risk to your safety or to the safety of someone else, I am required to assist you in accessing emergency psychiatric services for further assessment. This might include directing or escorting you to the nearest emergency room, or calling Emergency Medical Services to your location, and speaking with appropriate staff about why you may be at risk of harm (e.g., things you have said or done).

If you disclose to me information indicating the maltreatment of a child, I am required to notify the New York State Central Registry, which may result in an investigation into the safety of that child.

For Insurance Reimbursement

If you choose to use insurance benefits to help cover the costs of treatment, I am required to provide the dates of our sessions, a diagnosis code, and in some cases, progress notes and/or a periodic treatment summary of what we have worked on. This may be for the purpose of the insurance company evaluating the progress of your treatment specifically, or evaluating my provision of services to people generally.

Progress notes include notes about your general state of being during our meetings (for example, your mood, degree of emotionality, your general cognitive functioning, etc.); the general reasons for your participating in treatment, the general focus of each session, what types of intervention I used, what progress is being made, any coordination of your care, and any recommendations I may have.

In some cases (e.g., where a safety risk may be present), I may also be required to provide notes on contact in between sessions with you and/or someone related to your care, such as a family member or significant other; or notes about a session I have with a significant person in your life (either with or without you present).

In cases of longer treatments, some insurance companies require therapists to discuss the treatment more in-depth with a company representative to determine whether there is a need for on-going coverage.

For legal Subpoenas

If I am subpeonaed by a court of law, I am required to provide the written records I have kept (described above).

A Note about “Process Notes”

To maintain continuity between sessions, I take notes during session times. These notes are considered separate from your official record, and are for my own reference. They are protected under law, and cannot be subpoenaed or required by insurance companies. In most cases, I am happy to share these notes with you upon request, unless I believe it would result in some emotional harm.

Provision of Records to Another Service Provider

In the event you seek services with another provider, either as a supplement to services with me or in lieu of such, I am happy to provide a copy of your official record as well as of my Process Notes upon receipt of a signed Release of Information form authorizing me to do so.

Billing

Occasionally, I may seek assistance with billing matters (e.g., when there is some issue with processing an insurance claim). In such case, I may request a private administrative assistant or professional biller, who would have access to your name, date of birth, and insurance identification number (all required to speak with an insurance representative about a claim) as well as the date(s) of service in question. In this kind of situation, the individual providing assistance would not have access to your personal information stored in your record.

Use of Electronic Health Record

I use the electronic health record platform, SimplePractice to record and store all clinical records as described above. SimplePractice follows the most current security protocols, so that a security breach, while highly unlikely, is still possible.