Ethical Practice and Compliance

Please review the following information so we can discuss and process the information in our next session. You may not understand some of the professional jargon, so please bring your questions, comments, and concerns to the next session.

Thank yourself for taking these proactive steps to health and wellness. If you prefer not to read this section, and would rather listen to an audio recording of this information, the clinician offers this section as a YouTube video.

Understanding the Importance of Compliance in Mental Health Counseling

To ensure the highest standard of care and to safeguard the interests of clients, counselors adhere to a meticulous set of ethical, legal, regulatory, and professional standards. This adherence not only protects clients but also enhances the therapeutic relationship and fosters a safe environment conducive to healing and growth. Documentation of all aspects of mental health treatment is crucial in this age of accountability. It is the only evidence demonstrating the need and effects of treatment. Simply stating that a client has a certain diagnosis or claiming that therapy has been helpful to the client is an opinion but not evidence. Empirical evidence demonstrating that treatment was necessary and effective is essential. It is possible, and even compulsory, to document the outcomes of psychotherapy in objective, measurable terms without mechanizing or dehumanizing the process.

The Role of Ethical Standards

Ethical standards in mental health counseling provide a framework for what is considered appropriate and professional behavior by counselors. These standards are designed to guide counselors in situations that require moral deliberation and decision-making, ensuring that the client’s welfare is always the priority. Ethical guidelines, such as those provided by the American Counseling Association (ACA), address issues including confidentiality, dual relationships, and the importance of professional competence. Adhering to these standards helps prevent the exploitation of clients and avoids conflicts of interest, which are crucial for maintaining trust and integrity within the therapeutic relationship.

Legal and Regulatory Compliance

Legal requirements for mental health counselors vary by state but generally include licensure prerequisites, adherence to privacy laws like HIPAA (Health Insurance Portability and Accountability Act), and mandatory reporting laws concerning abuse or imminent harm. These legal aspects ensure that counselors are qualified to provide mental health services and that they do so in a manner that protects client privacy and safety. Compliance with these laws not only helps in providing high-quality care but also shields both the client and the counselor from legal repercussions.

The Importance of Professional Policies and Regulations

Professional policies and regulations are established by state boards and professional bodies to standardize the practice of mental health counseling. These include requirements for continuing education, supervision, and ethical conduct. These policies ensure that counselors remain up-to-date with the latest developments in their field, including therapeutic techniques and the evolving understanding of mental health disorders. By following these guidelines, counselors demonstrate their commitment to their profession and their clients, ensuring that they provide the most effective and informed treatment.

How Compliance Benefits Clients

Compliance with ethical and legal standards assures clients that their mental health provider is accountable and operates under supervised practices. This security fosters a safer therapeutic environment where clients feel secure to share sensitive information. By adhering to the regulatory requirements of ongoing education and ethical practice, counselors maintain a high standard of professionalism and competence. This commitment is vital in providing effective therapy and support. Strict compliance with laws like HIPAA ensures that clients’ personal and health information is protected, which is essential for maintaining confidentiality in mental health treatment. Ethical standards ensure that all clients are treated with respect and dignity, regardless of their background. This equity is fundamental in providing effective and unbiased mental health care.

Professional Standards

Standards of accountability in the mental health profession come from a number of sources. State boards such as psychiatry, nursing, psychology, social work, substance abuse, professional counselors, and marriage and family therapy, each have specific guidelines for licensees. Accrediting agencies such as the Commission of Accreditation for Rehabilitation Facilities (CARF) and The Joint Commission (TJC) and third‐party payers such as insurance companies and managed care organizations maintain specific documentation requirements to ensure accountability.

The processes and standards that counselors follow are not just bureaucratic formalities but are essential to the integrity and efficacy of mental health counseling. These guidelines ensure that clients receive care that is ethical, legal, and professional, fostering an environment where healing and personal growth can flourish. Clients are encouraged to discuss these practices with their counselors, gaining a clearer understanding of how they contribute to a successful therapeutic outcome. By doing so, they can actively participate in their treatment journey, reinforcing a partnership built on trust and mutual respect.

Mental health clients desire a treating professional who is knowledgeable, caring, empathic, and able to help them work through issues. However, they do not want treatment from someone who fully “plays it by ear” or says whatever comes into mind. A high degree of professionalism and knowledge is expected. Otherwise, why would counselors need graduate training? On the other hand, clients do not desire working with a therapist who is so scientific or technical that the human element is lost. A combination of art and science is necessary in the delivery of counseling.

Documentation is Required.

Documentation is used for several purposes including (a) objectively monitoring progresses and setbacks in treatment, (b) monitoring the effectiveness of current interventions, (c) working collaboratively with other professionals, and (d) audits from third parties such as those who pay for services, accreditation reviews, legal matters, and professional review boards. Very few therapists enjoy documentation; however, many therapists who have not done a good job of documenting have, unfortunately, realized its importance when their charts were audited.

Documentation begins at the first interview. The several documentation procedures conducted throughout therapy are interrelated. The information collected in the initial interview is necessary for writing the treatment plan. The treatment plan provides a guideline for the course of therapy, which is documented in the progress notes. Progress notes are necessary for writing a revised treatment plan. All of the information collected is needed in writing the discharge summary and assessing outcomes. When sound documentation procedures are followed, a written record of treatment will be available for review of (a) validation of the correct diagnosis, (b) the medical necessity of services, (c) therapeutic effectiveness, (d) appropriateness of services performed, (e) continuity of services, and (f) evaluation of therapeutic outcomes. The result is setting a high standard for mental health treatment.

Most third‐party payers do not cover counseling that is intended solely for “personal growth,” rather than treating psychopathology. This is not to say that counseling for personal growth is not helpful, but it is typically not covered by insurance. Thus, it is usually an out‐of‐pocket expense. Such counseling likely fits under the category of the services a life coach offers. Please be aware that insurance companies do not pay for services without adequate documentation and a definite mental health diagnosis and related impairments.

In the not‐so‐distant past, documentation consisted of little or no more than verifying that an interview took place, making a diagnosis, perhaps making a treatment plan, and writing rudimentary progress notes. Because there were few specific standards, documentation was a matter of subjective opinion. It was not given much attention in graduate schools. Although clinical judgment will always be an extremely important part of understanding client behaviors, there must be a balance of incorporating universal procedures (e.g., Diagnostic and Statistical Manual of Mental Disorders [DSM]‐5 criteria, professional regulations, accreditation standards, third‐party payer requirements, clinic standards, etc.), when documenting services. In the past, insurance companies that paid for mental health services listed few or no documentation requirements to validate a diagnosis or the client’s need for services. Clients receiving mental health services seldom knew their diagnosis or even if there was a written treatment plan. Now, the client’s input is an important part in formulating, following, and revising the treatment plan.

Today, in the age of professional accountability, clinical proficiency is absolutely necessary, but not sufficient, in encompassing all aspects of mental health services. Third‐party payers demand evidence that demonstrates both the need for and effectiveness of mental health treatment. An insurance company or an accreditation agency does not interview a client to determine the effectiveness of services. (However, at times, outcomes surveys are sent to clients.) The professional board by which the mental health professional is licensed will likely review a licensee’s records for a client when a complaint is filed. They all rely on written documentation from the therapist. Therefore, if services are not properly documented, the most skillful therapist could appear, on paper, to be ineffective with clients for the sole reason of inadequate documentation.

This can lead to significant multifaceted losses (termination of services, loss of insurance contract, reimbursement to the insurance company, suspension of licensure) to the therapist. There are cases in which very poor documentation has been reported to professional boards, leading to reprimands and required supervision, continuing education, and sometimes, license suspension. Documentation is a necessary part of the training and continuing education of mental health professionals.

Below is an outline of the key areas covered by compliance practices:

During the first session, I will develop a rapport with you, gain your trust, and create a therapeutic alliance, as I gather information from you, and I share my credentials, work history, clinical experience, formal education, graduate school internship, additional training and supervised practice, integrative theory and approaches to therapy. We will discuss your presenting problems and your long term goals of therapy. I will share the agreement for privacy and confidentiality, and the limits to confidentiality and privacy rules. I will cover health Insurance guidelines and requirements. I will address ethical standards, non-discrimination, and dual relationships. I will provide you with an orientation to the Client Account Portal in Therapy Notes and an orientation to the format of our therapy sessions. If you complete the paperwork before the session, it will reduce the time we spend in sessions covering the material, and help to improve the quality of the session.

During the first session we will discuss whether you were able to verify insurance coverage, eligibility, benefits, co-pays, deductibles, etc. I will verify your understanding of insurance company requirements and medical necessity requirements. I will ask you to be sure you submit a form of payment and submit the payment authorization form in your intake documents.

You should have already received your invitation to register for client account portal. We will review the information from the Client Information Form. We will review the information from the Client Insurance Authorization Form. We will review the Client History Form. If you have any questions or have not read it, we will discuss the Telemedicine information and instructions. If you have any questions or have not read it, we will discuss the document “Use of AI Software to Create Counseling Documentation.” If you have any questions or have not read it, we will discuss the document “Philosophical Basis and Therapeutic Orientation to Counseling.” If you have any questions or have not read it, we will discuss the document “Secure Messages and Electronic Communication.” If you have any questions or have not read it, we will discuss the document “Information about the Portal Documents and Forms Library.”

The following documents must be carefully reviewed and signed by the client for services to be considered “in compliance.”

An Advance Beneficiary Notice (VT Medicare and Medicare Supplement) to provide clients seeking services that are not covered by Medicare.
An Informed consent to therapy contract details the rights and responsibilities of the client and the clinician.
A Mental Health Counselor Public Disclosure Statement detailing the credentials, experience, work history, education, training, and licenses.
The Office of Professional Regulation Statutes and Contact Information detailing the rules and regulations of practice for mental health counselors, and the methods to file a complaint.
The HIPAA Notice of Privacy Practices Form outlining the federal health insurance portability and accountability act, and the clinician’s data and privacy practices.
The Confidentiality Statement: detailed within the informed consent agreement.
Your consent for electronic communication like email, phone, texts, and messages through the client account portal.
Your consent for telehealth sessions on the software Zoom, and the privacy information for telehealth by videoconference.
Your consent to record in person sessions for AI generated session notes, transcripts, and progress notes.
Your right to a good faith estimate, as guaranteed by the No Surprise Act: detailed within the informed consent agreement.
Any optional Releases of Information must be documented and signed, for collaboration and conferring with others about your care.

We will discuss insurance information about medical necessity, reimbursement, copays, deductibles, health savings accounts, and flexible spending accounts. We will discuss and agree on payment options, policies, and keeping a payment method on file, and the clinician’s billing process: see the informed consent agreement.

Assessment and Outcome Measures

Assessments and Outcome Measures are a requirement, they give us a subjective measure of what you are experiencing in the recent past. Some will measure in weeks, months, or years. A Biopsychosocial Assessment is necessary for a detailed history affecting your present circumstances. Clinical Interviews conducted in sessions for diagnosis which is a requirement for ethical and insurance reasons. Treatment Planning Guidance Forms (Therapy Notes Client Portal) because new evidence-based practices and guidance from state and federal agencies show the importance of involving clients in their treatment.

I will ask you to write your own statements on your problems and goals. You will have the option to assist me in choosing the best objectives and interventions. I will write an integrative summary that includes differential diagnosis, biopsychosocial summary, strengths, needs, abilities, preferences, and justification for therapy. I will provide a medical necessity statement if it is requested in writing.

Signed Treatment Plans are Required by Insurance Regulations

I will ask you to review and sign your treatment plan, and will be available to address any concerns, or answer any questions about it.

As a professional, it is my duty and responsibility to maintain enrollment in the insurance panels. I periodically conduct random chart reviews for compliance, sometimes by peer review and mostly internally completed by me. The peer who reviews the chart will have signed a HIPAA compliant business associate agreement, for consultation and supervision services.

I write progress notes with the assistance of an AI dictation or recording, based on type of meeting and your signed consent to hold myself accountable and remain in compliance. Insurance Claims and Billing Statements will be processed in a timely manner, with delays being explained as soon as possible. I am always engaging in the following Continuing Education: Diagnosis, Ethics, Diversity, Equity, Inclusivity, Documentation, Policy, Procedures, Evidence Based Interventions, and Mental Health Topics. I will maintain Privacy and Security Compliance within HIPAA guidelines and ethical standards. I will pass along any updates and/or communication from third party payers (insurance). I will participate in regular consultation (Legal and Ethical) with other professionals.

My practice is guided by professional associations (American Mental Health Counselors Association, American Counseling Association, Substance Abuse and Mental Health Services Administration, National Board of Certified Counselors, and Vermont State Office of Professional Regulation and Allied Board of Mental Health Professionals)

Continuing therapy sessions are informed by ACA Ethics, SAMHSA Recovery Principles, and ASAM Guidelines. Interventions are Evidence Based, Best Practice, and Medically Necessary. The approach is Cognitive, Emotional, Dialectical, Behavioral, Somatic, Social, Vocational, Educational, Financial, and Motivational (unknown whether some of these are covered) from treatment planning books created by well-respected authors and publishers.

Continuous assessment of client by the clinician with outcome measures ideally administered every 8th session. Treatment plan review and progress will be evaluated on a mutually agreed to basis (ideally every 8th session). I will ask you to complete Session Rating Skills periodically to evaluate therapy and clinician. Psychoeducational lessons, reading, videos, skills practice, journaling, progress recording, health and wellness life domain plans and goal creation will be assigned in between sessions. Reviews of progress notes are not recommended but possible with written request.

I am required to maintain accurate records of each session and your progress in therapy. The heading on every page of each note will detail the following information and the footer will display the page number. The clinician’s name, credentials, license, and National Provider Identification number. The client’s identifying information, name and 2 IDs, and the client account number. The date of service, and location of the session (office or telehealth). The next section will include subjective client reports. The client’s statements from check in and throughout session, issues discussed, themes and patterns, insight, awareness, verbalized, and expressed.

The information shared is intentionally vague and no names are ever recorded in a note. The next section will include objective data, including the time we start, the time we stop, locations, diagnostic information, CPT service code. It will include clinician’s observations in session of the client demeanor, appearance, mood, affect, motor activity, expressions, attitude toward therapist and interventions, response to the interventions, and homework follow up discussion. The next section will include any treatment plan progress. Any stagnation or regression is only recorded if it is clinically significant. The report will include objectives achieved, interventions used, goals measured, the modality rationale, and the client’s overall progress in therapy.

The next section of the note will include an assessment of this session and therapy overall. It will include professional assessments of diagnosis and justification, global functioning in daily activities of living, medication compliance and effectiveness, response to treatment, mental orientation, mental status, prognosis, level of risk (danger to self, other, property), and medical necessity. The last section of each progress note includes our cooperative plan for future direction of therapy and sessions, next steps planned, and homework assigned.

This clinician continuously conducts assessments or obtains information for each person served:

In a manner that is respectful and considerate of that person’s specific needs
That identifies the expectations of the person served
That provides for the use of assistive technology or resources, as needed, in the assessment process
That is responsive to the changing needs of the person served
That includes provisions for communicating the results of the assessment to professionals, the person served, appropriate others, that provides the basis for legally required notification, when applicable.
Conducted by qualified personnel knowledgeable to assess the specific needs of the persons served and trained in the use of applicable tools.

The assessments include information obtained from:

the person served
family members, when applicable or permitted
friends or peers, when appropriate and permitted
other appropriate and permitted collateral sources.

The primary assessment gathers sufficient information to develop an individualized, person‐centered plan for each person served, including information about the person’s:

personal strengths
individual needs
abilities and interests
preferences
presenting problems
urgent needs, including suicide risk
previous behavioral health services, (diagnostic information, treatment information, efficacy of current or previously used medications, physical health history and current status)
diagnosis(es)
current mental status
current level of functioning
pertinent current and historical life situation information (age, gender, employment history, legal involvement, family history, history of abuse, relationships, including natural supports)
issues important to the person served
use of alcohol, tobacco, and/or other drugs
need for, and availability of, social supports
risk‐taking behaviors
level of educational functioning
advance directives, when applicable
medication use profile
medication allergies or adverse reactions to medications
adjustments to disabilities/disorders.

The primary assessment:

is conducted within specific time frames
results in the preparation of an interpretive summary (based on the assessment data)
used in the development of the treatment plan
identifies any co‐occurring disabilities/disorders that should be addressed in the development of the individual plan.

For my Clients: You will be asked to sign for receipt and acknowledgement that you have read, understood, and agree to the items contained in this document, and agree to sign electronically.