Confidentiality is a means of providing clients with safety and privacy. Confidentiality of information between the therapist and the client is protected, with the following exceptions:
The issue of confidentiality will be discussed during the contracting stage prior to the first session where any concerns can be addressed at this stage. In order to protect client anonymity, client codes are used on notes and client identity is protected when engaging in supervision.
Client information is generally provided by the clients to the therapist. However, there are exceptions when information is obtained from external sources:
Therapists are legally and ethically obliged to maintain basic notes and records. Client notes facilitate therapists to track progression in therapy.
Information recorded includes details of themes discussed in sessions, plans, interventions used, observations made during sessions, contact between sessions, artwork.
Details regarding GP contact details, medications, next of kin are also retained on file in case of emergency. Client information is stored on an encrypted laptop, and written notes are retained in a secure locked storage area.
Access to client information is protected. Clients have a right to request notes and records relating to themselves personally in writing under the Freedom of Information Act. In addition, notes can be court ordered. Information can be shared with other professionals with your consent or where you, or someone else or a minor is deemed to be at risk.
Legally it is required for information to be maintained for a minimum of seven years after therapy ends.