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

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

General file information

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

Documentation of service

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

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