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Florida Administrative Code (Last Updated: November 11, 2024) |
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64. Department of Health |
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64b4. Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling |
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64B4-9. Client Records |
1Psychotherapy records are chronicles of a dynamic psychotherapeutic relationship and are to be accorded the dignity and respect due such a relationship. Psychotherapy is for the client and all records constructed shall respect the integrity and privacy of that relationship.
41(1) A psychotherapy report is a summary of information derived from the psychotherapy records which addresses a specific request as authorized by the client.
65(2) A psychotherapy record shall contain basic information about the client including name, address and telephone number, dates of therapy sessions, treatment plan and results achieved, diagnosis if applicable, and financial transactions between therapist and client including fees assessed and collected. A record shall also include notes or documentation of the client’s consent to all aspects of treatment, copies of all client authorizations for release of information, any legal forms pertaining to the client, and documentation of any contact the therapist has with other professionals regarding the client.
153(3) Regardless of who pays for the services of the psychotherapist, a client is that individual who, by virtue of private consultation with the psychotherapist, has reason to expect that the individual’s communication with the psychotherapist during that private consultation will remain confidential.
196Rulemaking Authority 198491.004(5), 199491.0148 FS. 201Law Implemented 203491.0148 FS. 205History–New 12-11-91, Formerly 21CC-9.002, 61F4-9.002, 59P-9.002, Amended 2-11-98.
