OFFICE POLICIES

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Client Records

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Client Records

Do you keep records related to my therapy?

The laws and ethical standards of my profession require that I keep treatment records. The main purpose of these records is to benefit you, the client. Keeping records allows a psychologist to document and review the delivery of psychological services. They also provide a history and current status of your therapy in the event that you seek psychological services from another mental health professional and you authorize me to transmit these records or information about your treatment to that professional. Record keeping allows me to plan and implement an appropriate course of psychological services, to review our work as a whole, and to monitor my work more precisely.

What do these records contain?

At the minimum, these records include identifying information (e.g., name, age, psychosocial history), dates of services, types of services, fees, any formal assessments or test results, the treatment plan, notes of consultations with other professionals or sources of collateral information, and authorizations to release information. The informal psychotherapy notes I make about sessions and that are kept in your file are a work product and not available for inspection as part of the record.

Can I inspect my records?

You are entitled to inspect your records with certain limitations. Because these are professional records, they can be misinterpreted and/or be upsetting to untrained readers. If you wish to inspect your records, I recommend that you review them in my presence so that we can discuss the contents. [I am sometimes willing to conduct a review meeting without charge.] Alternatively, I will be happy to send them to a mental health professional of your choice who can help you understand the content. You will be charged an appropriate fee for any materials and time spent in preparing information requests.

What if an attorney subpoenas my records?

A subpoena, even when issued by an attorney, carries the authority of a court and cannot be ignored. I would need your written authorization or a legal mandate to release information. Without your written authorization, I would consult with an attorney and be guided by his or her instructions. I will keep you informed about all actions I am required to take.

What if I want you to give information to my attorney?

If you choose, I will prepare and send a summary of your treatment, including the DSM diagnosis, psychosocial history, and treatment progress to your attorney or other professional whom you designate, and there will be an extra charge for these services. Sometimes an attorney demands the entire record, which I advise against your authorizing. Even so, if you want the entire record sent, you must provide me with written authorization to do so.

Please be aware that making your records available to an attorney and subsequently to the court means you will lose confidentiality in all that we have discussed. I may also be required to testify, and anything that we have discussed may become part of the legal record. Of course, there will be an appropriate charge for preparing a summary, copying and sending the entire file, or testifying in court. Furthermore, litigation can lead to the termination of our therapy relationship, because my participation in such legal proceedings may negatively affect our work.

Dr. Joyce Nash, PhD    (650) 329-1000