The records I keep for clients include the following:
- Initial data, including contact information for the client and for someone to contact in the event a client is experiencing an emergency and needs assistance
- Notes taken from the first 1-3 visits, as I am getting to know clients and asking about details of clients’ history and experiences to assess clients’ needs
- The dates of office visits and general themes discussed (example: “Discussed present work-related problem”), specific worksheets reviewed (example: “Reviewed ‘Goals and Values’ worksheet”) or exercises (example: “Practiced visualization exercise”)
- Correspondence between clients and myself
Your records, as well as what we discuss in treatment, are all confidential, meaning that I alone have access to them, although there are some limitations to this:
If you choose to use insurance benefits to help cover the costs of treatment, I will need to provide dates of attendance, a diagnosis code, and in some cases, a periodic treatment summary of what we have worked on. In cases of longer treatments, some insurance companies require therapists to discuss the treatment more in-depth with a company representative to determine on-going coverage.
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 your disclosures related to risk of harm.
If you disclose to me information indicating 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.
If I am subpoenaed by a court of law, I am required to provide the written records I have kept (described above).