Code of Colorado Regulations
700 - Department of Regulatory Agencies
734 - Division of Professions and Occupations - State Board of Unlicensed Psychotherapists
4 CCR 734-1 - UNLICENSED PSYCHOTHERAPISTS RULES AND REGULATIONS
Section 4 CCR 734-1.12 - RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. sections 12-245-204(4), 12-245-224(1)(u))

Universal Citation: 4 CO Code Regs 734-1 § 12

Current through Register Vol. 47, No. 17, September 10, 2024

A. General. Except as provided in subsection (G) of this Rule every unlicensed psychotherapist engaged in the practice of psychotherapy as defined in section 12-245-202(14), C.R.S., shall create and shall maintain records on each of his/her psychotherapy clients. The unlicensed psychotherapist shall retain a record on each psychotherapy client for a period of seven years commencing on the date of termination of psychotherapy services or the date of last treatment with the client, whichever is later. Exception. When the client is a child, the record shall be retained for a period of seven years commencing either upon the last date of treatment or when the child reaches eighteen years of age, whichever comes later.

B. Record. Every unlicensed psychotherapist shall maintain, as applicable to the mental health services rendered, a record containing the following information:

1. Name of treating therapist;

2. Client's identifying data to include name, address, telephone number, gender, date of birth, and if applicable the name of the parent or guardian. If the client is an organization, the name of the organization, telephone number and name of the principal authorizing the mental health provider's services or treatment;

3. Reason(s) for the psychotherapy services;

4. Mandatory disclosure statement(s);

5. Dates of service including, but not limited to the date of each contact with client, the date on which services began, and the date of last contact with client;

6. Types of service;

7. Fees;

8. Any release of information;

9. The records must be legible and prepared in a manner that allows any subsequent provider to yield a comprehensive conclusion as to what occurred;

10. Name of any test administered, each date on which the test was administered, and the name(s) of the person(s) administering the test;

11. Information on each referral made to and each consultation with another therapist or other health care provider. This information shall include the date of referral or consultation, the name of the person to whom the client was referred, the name of the person with whom consultation was sought; the outcome (if known) of the referral, and the outcome (if known) of the consultation;

12. Adequate and reasonable case management records;

13. Records of counseling, interview notes, correspondence, audio or visual recordings, electronic data storage, and other documents considered professional information for use in counseling; and

14. A final closing statement (if services are over), if applicable.

D. Record Storage. Every unlicensed psychotherapist shall keep and store client records in a secure place and in a manner that assures that only authorized persons have access to the records and protects the confidentiality of the records and the information contained within the records.

E. Transfer of Records. Whenever an unlicensed psychotherapist deems it necessary to transfer her/his records to another unlicensed psychotherapist or other health care provider, the unlicensed psychotherapist making the transfer shall obtain the client's consent to transfer (when possible).

F. Disposition of Records. If the unlicensed psychotherapist is not available to handle her/his own records, the unlicensed psychotherapist and/or his estate shall designate an appropriate person to handle the disposition of records. A plan for the disposition of records shall be in place for all unlicensed psychotherapists for the following conditions:

1. Disability, illness or death of the unlicensed psychotherapist;

2. Termination of the unlicensed psychotherapist's practice;

3. Sale or transfer of the unlicensed psychotherapist's practice.

G. Record Destruction. Every unlicensed psychotherapist shall dispose of client records in a manner or by a process that destroys or obliterates all client identifying data. However, records cannot be destroyed until after seven years or as otherwise provided in these Rules or any other applicable rules or statutes.

H. Record keeping in agency/institutional settings. An unlicensed psychotherapist need not create and maintain separate client records if the unlicensed psychotherapist practices in an agency or institutional setting and the unlicensed psychotherapist:

1. Sees the client in the usual course of that practice;

2. Keeps client records as required by the agency or institution; and

3. The agency or institution maintains client records.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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