Client and other professionals may review these records. It is important that the practitioner be sensitive to the language. 

Note on documentation

The date, duration and type of psychotherapy services and session notes. These notes should be updated for each contact with a client.

University of Illinois at Urbana-Champaign

* General file information
* Documentation of service
* Other information

Three types of record keeping content

Vinay, B., Lakshmi, J., & Math, S. B. (2016). Ethical and legal issues in psychotherapy. In Ethical Issues in Counselling and Psychotherapy Practice (pp. 199-217). Springer, Singapore. https://doi.org/10.1007/978-981-10-1808-4_13

Ethical and Legal Issues in Psychotherapy

Demographic details, presenting problems, diagnosis, intervention plan, fee agreement, billing information and informed consent.

General file information

Documentation of service

Assessment data, crisis management documentation, consultation with other professionals, and telephone and email contacts.

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