Privacy, intake and consent in private practice: Good Practice Guideline
“PACFA is committed to sustaining and advancing best practice in the clinical practice of counselling and psychotherapy” (PACFA Code of Ethics 2017, p.8) and promotes professionalism and a commitment to quality of service. This resource focuses on key documentation needed by PACFA registrants working in or contemplating working in private practice.
Four documents are described in this Good Practice Guideline to support registrants:
- privacy policy, which clarifies for a client the practitioner’s legal obligation and commitment to the protection of their personal information,
- intake form, which provides a transparent and consistent mechanism for the practitioner to gather personal and identifying information about a new client and assures the client regarding the practitioner’s commitment to the confidential protection of this information,
- informed consent form, which details for the client the nature and terms of the relationship with the practitioner prior to the commencement of therapy, and
- consent for information release/exchange form, which ensures that the client is actively informed and engaged in any disclosure by the practitioner of their personal information that is not legally mandated.
Maintaining client records: Good Practice Guideline
These enable members to engage with PACFA’s ethical framework with regard to record keeping. The Code of Ethics commits members to put the client’s interests first, be accountable to high professional standards, keep accurate client records and comply with the relevant privacy laws. (2019b, pp. 9–10). These guidelines answer some of the question we have received from members such as "How long do I need to store client records for?", "I am starting a private practice, what information do I need to keep in a client file?", " What happens to my client records if something happens to me?" and "I am closing down my practice, what do I do with my client records?".
In the Maintaining client records: Good Practice Guideline you can find information for the following areas:
- What do we mean by client records?
- Purpose of client records
- Choosing our record keeping system
- Record keeping and informed consent
- Limits to confidentiality of our client records
- Ownership of our client records
- Access to client records within an organisation
- Client access to their records
- Client records and legal proceedings
- For how long do we keep our client records?
- Disposing of our client records
- Planning for the unexpected
- Relevant codes and relevant legislation
Writing session notes: Good Practice Guideline
These provide good practice guidance to enable members to align with PACFA’s ethical framework in writing their session notes. Session notes summarise the content of each session with a client. They are variously described as case notes, process notes, consumer notes, or consultation notes and they form a significant part of the Client’s Record. These guidelines answer some of the question we have received from members such as "What is included in session notes?", "Is there a particular style that is best for case notes?", "What happens if I need to change my notes?".
In the Writing session notes: Good Practice Guideline you can find information for the following areas:
- Why do we write session notes?
- What information should we include?
- Paper-based or electronic?
- Is there a particular style to use?
- What not to include in session notes
- Timeliness of session notes and making amendments