Client Files

Student therapists must complete session summaries within 48 hours of each session.  This ensures that records are current and accurate.  Uncompleted session summaries and incomplete client files can place the clinic and your own professional career in a compromised position with the legal system.  Additionally, case notes must be completed within a week of the date of the session or the client contact hour(s) may not be counted.  If a summary is not done before the grace period, it still must be completed. Failure to complete session summaries is a serious problem.  Failure to do so in a timely way will lower your grade and may result in having to take an additional semester of Practicum.  In some situations, it can be unethical conduct and face the corresponding consequences.

Session summaries/case notes are valuable for student therapists, supervisors and are critical for documentation:

• For the student therapist: to allow the student therapist to reflect after each session on what their goals were for the session and what actually transpired.  The student therapist then takes this information to develop a more complex assessment, and plan for the next session.

• For the supervisor: to allow the supervisor on a weekly basis to review the student therapist's work with clients, especially work that has not been covered in depth in supervision.  The supervisor is in part responsible for the clinical work done in the Center so it is critical for them to know the process and progress of each case.  This affords opportunities to track the course of therapy and offer constructive suggestions about the course of therapy as it is described in the summary.

• For official documentation: to accurately reflect the progress of the case.  Often the case records are requested by the client or through the court system and it is imperative that they be professionally done, clear, and concise, with proper grammar and spelling.  Session summaries that are not completed in this way may be returned to be rewritten.

Session summaries/case notes are to be completed in Titanium.  Notes will have the following format: Report, Observation, Assessment, and Plan

a)      Report should include a summary of the content of the session (i.e., what the client said, what issues were discussed, what the therapeutic intervention entailed, etc.)

b)      Observation should include a description of the process of the session, (i.e. how the clients interacted with each other and/or with you, description of the client's affect, non-verbal communication, etc.)

c)      Assessment should include the student therapist's conclusions based on the Report and Observation sections.  How is the case being conceptualized?  What might be areas to explore further?

d)      The Plan for the following session is entered in the last section.  This should state what the therapist plans to do in the next session (what will be the follow up questions, activities, or interventions)?  The Plan follows from the Report, Observation, and Assessment sections.

Reminders about session summaries:  The session summary is a legal document, not a note by the student therapist to themselves.  Write the note concisely and to the point.  Base observations on what is seen and heard and document that.  Avoid making judgments that cannot be backed up.  If a student therapist wants to include an opinion or intuition, own it specifically as such, not as a fact.  This can be done by prefacing the comment with "In my opinion" or "It seems to me" or "The client presents" or "The client appears" and refer to the observation.  A session summary cannot be changed after the supervisor signs it.  Alteration of a session summary or destruction of documentation is illegal.

Within the first 6 weeks (or 4 sessions) of opening a case, an initial treatment plan must be developed.  Treatment plans should be reviewed on a regular basis (every 3 months) while a case is open.  

Treatment plans should be done in collaboration with the client.  Goal statements should be framed in positive terms and be very specific.  What will change as a result of therapy?  The Measurement of Progress should also be very specific.  How will the therapist or client know that change has occurred?  What will increase or decrease and how will it be measured? Lastly, Interventions are the techniques or approaches used in sessions to accomplish the goals.

Student therapists initiate the treatment plan with clients and then review them with their supervisor.  Once approved by the supervisor, the student therapist completes the plan in Titanium.  The client and therapist electronically sign it.  The note is then forwarded to the supervisor for signature.  Student therapists must seek input from their supervisors before signing treatment plans.  Using clinical language and specific statements can take time to develop, so supervisors may assist in the process.  There is space to record client feedback about the services they have received.

When receiving a transfer case, it is important to check the treatment plans.  They may need to be updated or developed with the new therapist.

All telephone calls to and from clients are to be documented in Titanium.

If there are letters written to or for the client, copies must be made and kept in the electronic file. Any letter MUST be reviewed by a supervisor.  Letters or summaries detailing any clinical work MUST be cosigned by the supervisor of the case (e.g., letters of support, treatment summaries, etc).  When providing a letter of support, be sure to also keep an original of the letter in the physical chart.

Student therapists are not to use email for correspondence with clients.

It is common in the practice of marriage & family therapy that you will need to contact other providers or important people in a client's life to provide the appropriate standard of care to your client.  Before discussing treatment, progress or even confirming/denying a therapeutic relationship with a client, the student therapist must talk with their client and have the client sign a release allowing you to make contact with this other person.

All correspondence with other parties related to the care and treatment of your client must be documented in Titanium.

All correspondence with other parties that includes confidential information should occur over the phone or fax, not through email.

When a client draws on the white board or paper, does a sand tray, design with blocks, etc., you will need to take a picture of it with the clinic camera.  Do not take pictures with your cell phone.  There is a log sheet in the clinic office to record your pictures.  The Clinic Administrative Assistant will save your pictures to your V Drive and send an email letting you know the image has been downloaded.  Once you have received this message, you can attach the image to your case note in Titanium.  If you have not received an email, stop at the front desk to see if the Clinic Administrative Assistant saved your picture.  When possible, write down the case number on the white board/drawing.  This will help identify the picture.

While sessions are occurring on Zoom, screen shots of white board or other activities can be saved to the V drive and then uploaded to the Titanium.

For our transgender and non-binary clients seeking letters of support, please ensure the readiness packet is completely filled out.  If the process is not finished, you will need to note why.   An electronic copy should be attached in Titanium.  Letters for support are to be printed on letterhead, signed, and scanned to be attached to the electronic file in Titanium.  A Trans Team Readiness Checklist can be used to help ensure you complete all tasks related to the readiness process for clients.  This can be found below, or in the clinic office.

The CFTC maintains client records in a confidential manner consistent with the law, the guidelines of the AAMFT and the state of New York. Subject to legally required exceptions, records will not be released to anyone without the written consent of the client.

If a request for the record comes from an outside source, do not forward Center documents without a consultation with the supervisor and the Clinic Director.  It seldom causes problems to NOT release records but releasing records without thorough consideration can be detrimental.

In many cases, a phone consultation or brief written summary may be sufficient.  Case documents and notes that apply to others who have been in the therapy session with them are confidential and require a release from that individual(s).

Clients may legally request access to their files. If a client requests a hard copy of their file, this first needs to be discussed with the supervisor and Clinic Director.  Then the risks and benefits of having the record should be discussed with the client.

Any client that requests copies must make the request in writing, provide a photo ID to verify identity (which will be photocopied), and sign a release clarifying that they are responsible for maintaining the privacy of their record.  For clients that are unable to come to the Center to initiate their request, the written request for records must be notarized. Files will be reviewed to ensure they only contain information about the client.  Reviewing and copying may take up to a week to complete. 

Clients also have a right to see their files, but it is advisable to ask them what they hope to gain from seeing them.  Sometimes the written file can lead to misunderstandings and it may be more helpful to have a conversation about their concerns.  If they still want to see their file, they can, but only aspects that apply to that client.  Any client requests to read records should be brought to the attention of the supervisor and the Clinic Director.  Case documents and notes that apply to others who have been in the therapy session with them are confidential and require a release from that individual(s).