Informed Consent, Client Records, and Confidentiality
Informed consent
Obtain consent before the first session and update it when the plan changes. Explain the technique, expected sensations, risks, draping, and the client’s right to refuse or stop at any time. Consent must be voluntary; a signed form does not cure coercion or a boundary violation. For minors, follow the Board’s parental or guardian consent rule. Document the consent discussion, not just the signature.
Records and confidentiality
Keep contemporaneous records: date, areas worked, techniques, client response, adverse events, referrals, and consent. Store records securely and release them only with a valid authorization or as required by law. Confidentiality covers identity, health information, and the fact of treatment.
Worked example
An attorney sends a subpoena for a client’s records. The therapist should not immediately fax the full file. Verify the subpoena’s validity and jurisdiction, notify the client unless legally barred, and release only the records required. A subpoena is a legal demand, but it does not automatically waive all confidentiality protections.
Traps
Consent once does not cover every future session. Do not discuss clients in public or on social media. Do not alter a record after a complaint; add a dated addendum. Do not assume email or text is secure.