Informed Consent, Client Rights, and Recordkeeping
Domain 5 tests what the client is told, what the client may access, and how the record is kept.
Informed consent
Informed consent is an ongoing process, not a signature at intake. It should cover the nature of counseling, fees and billing, confidentiality and its limits, supervision status, risks and benefits, alternatives, the right to withdraw, emergency procedures, record policy, and telehealth-specific risks. Consent for minors and for release of information must follow Maryland law and Board rules.
Client rights and records
Clients have rights to privacy, respectful treatment, information about their care, access to their records, and a grievance process. Records must be accurate, timely, secure, and retained for the period required by Board regulation; records of minors and records involved in litigation may need longer retention. Release requires a proper authorization, and electronic records require password protection, encryption, and secure disposal.
Worked example
A former client asks for a copy of the record. The counselor verifies identity, reviews the record for third-party information, provides a copy (or a summary if permitted), documents the request and response, and charges only an allowable copying fee. The counselor does not withhold the record solely because the client has an unpaid balance.
Traps
- Using a one-time intake form as the whole consent process.
- Failing to document supervision or collateral contacts.
- Destroying records on a personal schedule instead of the Board's retention rule.