This document outlines Boradleaf Psychotherapy responsibility and practices in respect of information on clients and explains our policies on confidentiality and data protection.
Confidentiality
The Boradleaf Psychotherapy Service will not pass on personal information about a client (including information on attendance) to anyone outside the Service subject to the following exceptions:
- Where Gabriel Facchini has the express consent of the client to disclose the information or data
- Where Gabriel Facchini would be liable to government, civil or criminal court procedure if the information was not disclosed
- Where Gabriel Facchini believes the client is likely to harm themselves or others
In any of these circumstances, Gabriel Facchini will normally encourage the client to pass on information to the relevant person/agency. If there is no indication that this has happened, and if the crisis or potential/actual harm is sufficiently high risk, the counsellor will extend confidentiality to the relevant professionals without consent. However, consent to disclose information will be sought from the client, if at all possible.
Supervision
In line with my professional requirement, Gabriel Facchini discusses client work with a external supervisor. In this process, the identity of the client may be revealed but any notes made by the consultant or supervisor are anonymised and held securely. The purpose of supervision is to help the counsellor to reflect on their work.
Liaison and correspondence
With the permission of the client it may be appropriate for the counsellor to liaise with or write to a third party, for example, personal tutor, GP or the Consultant Psychiatrist for the counselling service. In the case of telephone calls, the purpose of the call will be discussed with the client prior to the call. Permission will not be required from the client if they are at risk of harm to themselves or others.
Record Keeping and Data Protection
It is usual practice for counsellors to keep records on clients and their sessions for up to six years. Counselling notes record background information and the issues raised and worked on in the sessions. These will vary in length and detail. Points of concern are also noted. All notes are kept safely under lock and key or, more commonly, held on a secure server within a confidential encrypted data base protected by both password and key code.
Access to notes
Under the Data Protection Act, clients have a right of access to all notes kept on them. If those notes contain references to other individuals these may not be available to the client, as protection is also granted to third parties. It will be important not just to show the notes to the client, but for the counsellor to talk to them about what their file contains and why. Some notes are in shorthand and may need explaining.
If a client’s file includes a letter or additional information from the person responsible for their clinical care, usually their GP or psychiatrist, consent from the relevant practitioner must be obtained before the correspondence is disclosed.
If a client wishes to see their file, they should ask Gabriel Facchini giving two weeks’ notice.
Security
All notes and records are kept securely locked within the Service or in electronic form within the secure, encrypted database described above.
In line with legal requirements, counselling notes are kept for 6 years. After this time they are destroyed by shredding or deleted from the database.
Codes of ethics
The counsellors adhere to either the British Association for Counselling and Psychotherapy Code of Ethics and Practice.