Documentation & Record Management
For each client, therapist and clinician make an initial consultation and/or assessment report and evaluation/termination report. All documents related to the client’s health information, including diagnosis, are strictly confidential. Documents are provided to client and/or client’s caregivers upon request.
Each session may include audio and/or video recordings (A/V recordings). These recordings are kept in a monitored and locked area for confidentiality and used for clinical purposes only (i.e., assessment, evaluation, tracking client progress, documentation, etc.)