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Therapists take confidentiality seriously. They understand that clients need a safe place to disclose their most private thoughts and feelings. In almost all cases, your personal information is held in strict confidence. Only in extreme cases will your therapist need to break confidentiality to keep you or others safe.
Notes should clearly state the client's symptoms and progress, as well as any treatments provided during sessions. Avoid using vague terms or abstract concepts that are open to interpretation, and focus on providing clear descriptions of the client's condition, thoughts, and behaviours.
Intake notes are a type of note used specifically in psychotherapy settings and mental health. They include detailed information about the mental health history of the client, current symptoms and concerns, as well as personal and social history, family history, and any previous treatment received.
It is important to note that California law differs in this regard. California law allows providers to deny access if the provider determines there is a substantial risk of significant adverse or detrimental consequences to a patient in seeing or receiving a copy of the records. (Cal. Health & Safety Code § 123110.)
These separate "process notes" are what we are calling "psychotherapy notes." Summary information, such as the current state of the patient, symptoms, summary of the theme of the psychotherapy session, diagnoses, medications prescribed, side effects, and any other information necessary for treatment or payment, is ...