The Solo Telehealth Practice: What an LMSW May Do Independently
An LMSW in Albuquerque has 14 months of post-master's experience and wants to open a solo private practice. She plans to accept a 13-year-old client with suicidal ideation, diagnose major depressive disorder, and provide weekly telehealth therapy from her home. Her supervisor is an LCSW who lives in Colorado and holds only a Colorado license; they have met by video for one hour each month and have never filed a supervision plan with the New Mexico Board. The parents pay cash and have asked that no diagnosis be shared with the child's school. The LMSW's proposed caseload is 22 clients, nine of them minors.
1. May the LMSW open this practice, diagnose the client, and treat her independently? What must change before she sees clinical clients?
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No. Under the Social Work Practice Act (NMSA 1978, §§ 61-31-1 et seq.) and 16.63.1 NMAC, the LMSW is a supervised license. Independent clinical practice - including diagnosing and treating mental disorders without supervision - requires the LCSW. The LMSW may provide clinical services only under a supervision arrangement the Board approves.
Three problems are visible. First, the supervisor is not New Mexico–licensed, so she cannot supervise for New Mexico licensure unless the Board specifically approves her. Second, one hour a month, by video, with no written supervision plan, is far below the regular documented supervision the rules contemplate. Third, a solo caseload heavy in high-acuity minors is inconsistent with supervised practice.
The correct move is to delay opening, secure a New Mexico–licensed LCSW supervisor, file the plan, and build the caseload under that supervision.
2. How should the therapist handle the parents' request that no diagnosis be shared with the school?
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The request not to send the diagnosis to the school is workable; the request to conceal it from the parents is not. Diagnosis and treatment planning belong in the record, and the parents as guardians generally have access to a minor's record absent a specific legal basis to withhold.
The therapist should explain that she will not send anything to the school without a signed authorization and that she does not routinely send diagnoses to schools. She should not agree to keep the diagnosis out of the chart or to tell the parents a different diagnosis. Document the parents' request, the explanation given, and any authorization ultimately signed.
If the parents later demand the record, the therapist should consider whether disclosure of any part is likely to harm the child and consult before releasing.
3. The client discloses a specific suicide plan involving pills in the home. What is the therapist's scope and duty?
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Suicidal ideation with a plan and means is a confidentiality exception. The therapist should complete a risk assessment, involve the parents (who are already involved and are a protective factor), arrange emergency evaluation or crisis services if indicated, reduce access to means, and document. She may disclose protected information to prevent serious harm.
The fact that the client is a minor does not make the parents the client - the client is the client - but parents are necessary allies in safety planning. If the therapist is practicing under supervision, she must involve the supervisor before or immediately after the crisis response. Scope matters here: if her supervised status does not authorize independent crisis management, she must escalate to the supervisor or emergency services rather than handling it alone.