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

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.

Other information

* General file information
* Documentation of service
* Other information

University of Illinois at Urbana-Champaign

Therapists are ethically and legally required to store records in a secure manner and to protect client confidentiality. 

Record keeping

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

Failing to maintain adequate client records potentially could lead to a malpractice claim because it breaches the standard of a mental health practitioner.

Learn Before

Related

Learn After