Current through Register Vol. 35, No. 18, September 24, 2024
A. The counselor or therapist shall safeguard confidential information obtained in the course of practice, teaching, research or other professional services. This includes a counselor or therapist's employees and professional associates as defined by law. The counselor or therapist shall disclose confidential information to others only with the informed written consent of the client or as outlined in Subsection B of this section.
B. Licensees or registrants shall inform a client of limitations of confidentiality. These limitations include, but are not limited to:
(1) Limitations mandated by the law.
(2) Disclosure when necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on the client or another person(s).
(3) Court orders in civil, criminal, or disciplinary actions arising from the therapy.
(4) Written waiver. Disclosure is limited to the terms of the waiver. If there is more than one party involved in the therapy, the waiver must be signed by all members legally competent to execute such a waiver (e.g. couples, marital couples, family, or group). When release of information pertaining to a client under the age of consent is requested, it must be signed by a parent or legal guardian. The counselor or therapist, to the extent the client can understand, shall inform the minor client of the limit the law imposes on his right of confidentiality.
(6) Reporting abuse of children and vulnerable adults, the counselor or therapist shall be familiar with any relevant law..
(7) Restrictions mandated by employing agencies.
C. Licensees or registrants shall ensure that all reasonable security measures are taken to ensure records and written data are protected from access by unauthorized persons.
D. Licensees or registrants shall ensure that the content and disposition of all records is in compliance with relevant state laws.
E. Licensees or registrants shall treat client information as confidential after the professional relationship between the counselor or therapist and the client has ceased.
F. Licensees or registrants shall exercise reasonable care to ensure that confidential information is appropriately disguised to prevent client identification when used as a case study, basis of supervision, teaching, research or other published reports.
G. Licensees or registrants shall explain to the client the limitations and foreseeable uses of confidential information.
H. Record retention
(1) Licensees or registrants rendering professional services to a client or billed to a third party, shall maintain professional records that include:
(a) the presenting problem(s) or purpose or diagnosis;
(b) the fee arrangement;
(c) the date and substance of each billed service;
(d) any test results or other evaluative results obtained and any basis test data from which they were derived;
(e) notation and results of formal consultations with other providers; and
(f) a copy of all tests or other evaluative reports prepared as part of the professional relationship.
(2) Licensees, registrants or agencies that employ licensed or registered counselors or therapists shall assure that all client records are maintained and secured for a period of not less than six years after the last date that professional services was rendered.
(3) Licensees or registrants shall store and dispose of written or electronic data and other recorded information in such a manner as to ensure client confidentiality.
(4) Licensees or registrants shall not withhold records under their control that are requested for a client's treatment solely because payment has not been received or otherwise provided by law.
(5) Licensees or registrants shall maintain on file a written plan in place that arranges for the storage, transfer, or disposal of client records that ensure confidentiality and safeguards the welfare of clients in the event of licensee or registrant incapacitation or death.
(6) In the event of the incapacitation or death of a licensee or registrant, the counselor or therapist's personal representative shall adhere to the written plan on file to assure that the deceased's clinical records are maintained and secured for a period of not less than six years after the last date that professional services were rendered. The decedent's personal representative shall store and eventually dispose of written or electronic data and other recorded information in such a manner as to ensure confidentiality and safeguards the welfare of the clients.
(7) Licensees or registrants shall provide clients with that client's summary of their clinical record upon receipt of a written request.
