The Employer's Report

Four distinct duties are colliding.

1. Confidentiality runs to the client, not the payer. Paying for a service does not purchase clinical information. The employer is a third party, and "sponsoring organization" in my consent form is too vague to constitute meaningful authorization for anything substantive.
2. My consent process was inadequate, and that is my error. The client cannot have given informed consent to a disclosure whose scope was never described. I need to fix this prospectively and say so, rather than hiding behind a sentence I wrote.
3. Scope and safety. Binge-purge behavior plus a PHQ-9 of 14 plus rapid weight loss is beyond nurse coaching. There is a duty to refer, and possibly a duty to protect - which requires me to actually ask the PHQ-9 item 9 question directly rather than inferring from a total score.
4. Non-abandonment and the business relationship. Ending the engagement abruptly over an ethical concern is its own harm, and the unpaid balance of a prepaid package is a real obligation.

What is not in tension: she has not threatened anyone, and there is no legal reporting pathway for an eating disorder in an adult. Her fear of disclosure is understandable but does not by itself create a permissive exception to confidentiality. Her request to tell no one does not, however, bind me out of referring her - the referral itself is not a disclosure to her employer.

First, before any reply to the employer, talk to the client.

• Tell her plainly that the employer has asked for a summary, that I will not send clinical content, and that I need her written, specific authorization for anything at all. Show her the exact document before it goes.
• Acknowledge that my intake consent language was too loose and that I am correcting it. Owning this builds the trust that the disclosure requires.

What the employer may receive, with her signed release:

• Dates of attendance, number of sessions completed, confirmation of participation.
• Optionally, her own stated goals and her own summary of progress - written or approved by her.
• General, non-identifying psychoeducation about what nurse coaching is and what it does not treat.

What the employer may never receive:

• The binge-purge disclosure, body image content, PHQ-9 score or any screening result, weight data, or my clinical impressions.
• Any "recommendations" about her fitness for her role. That request is where a coaching engagement quietly becomes a fitness-for-duty evaluation, and I should decline it in writing.

Script to the employer: "I can confirm attendance and completion. Anything beyond that belongs to the employee, and I'd need her written authorization. I also want to flag that the consent language in our arrangement should be tightened before the next referral."

If pressed: hold the line, put it in writing, and note that a payer's request does not override the client's authorization requirement.

Sequence, most urgent first.

1. Ask the item 9 question directly, this session. "In the last two weeks, have you had thoughts that you would be better off dead, or of hurting yourself?" A total score of 14 does not answer it. If positive: assess intent, plan, means, and protective factors; do not leave her alone if risk is imminent; activate emergency resources; document contemporaneously.
2. Be honest about scope, without abandoning her. "This is more than coaching can hold, and I'd be doing you a disservice to pretend otherwise. I'm not going anywhere - I want to build the team around this." Refer for eating-disorder-specific assessment (a program or clinician with ED expertise), to her PCP for the weight loss and purging, and to a therapist for the depression. Offer to make the calls with her in the room rather than handing her a phone number.
3. Explain the confidentiality limit accurately. Say what I must share and under what circumstances - imminent risk, abuse of a dependent or elder - and that a referral conversation is coordinated with her consent, not behind her back. The fear that this "goes in my record" is realistic; treat it as a legitimate concern and address it with facts.
4. Document factually. Objective observations, disclosures in her words, actions taken, referrals made, and the safety assessment. No speculation, no labels I am not qualified to assign.

Managing the package and the relationship:

• Offer a choice: continue supportive coaching sessions while the clinical team takes the lead, or pause and refund the unused sessions. Do not keep billing for a service I have just said is the wrong service.
• Put the refund option in writing so the decision is genuinely voluntary and not a subtle pressure to continue.
• Correct the consent form for future clients: named recipients, specific categories of information, an expiration, a revocation clause, and a statement that clinical content is never shared.
• If the employer reacts badly, the answer is the same: the contract is with the organization, the confidentiality is with the person - and the next referral agreement should say so on page one.