Confidentiality Policy

The purpose of this Confidentiality Policy is to lay down the principles that I observe in maintaining individuals’ confidentiality.

I am bound by the BACP Ethical Framework for the Counselling Professions (2016) which states that I will protect the confidentiality and privacy of clients through the following:

• actively protecting information about clients from unauthorised access or disclosure
• informing clients about any reasonably foreseeable limitations of privacy or confidentiality in advance of our work together This policy sets out the type of information that I hold, who has access to it and how I keep it secure. It also highlights limitations to confidentiality and situations where I am unable to uphold confidentiality.

Types of Information Held:

Personal and tracking Information

I record certain personal and tracking details such as names, addresses, date of birth, preferred means of contact, referral information and dates of attendance. For safety reasons I also gather information on medical issues which may affect counselling; emergency contact details and medical contacts (e.g. GP; CPN; Psychiatrist). This information is stored in hard copy only in a secure locked filing cabinet in my counselling office. I am the only person who has access to this information. When clients complete this paperwork they will sign a consent section to note their agreement to this information being kept.

Assessment and Screening Records

With a random sample of clients I may use CORE-IMS assessment and outcome forms which can be used to assess clients’ level of distress, any risk factors and also progress. All data from CORE is anonymised and is held hard copy in a secure locked filing cabinet. The data pertaining to each client is freely available to them and this will be discussed with any client that is using CORE when they start their therapy.

Referral Information

In the event of a client being referred by a third party, I will make it known to the third party that details of the client’s history or current situation will only be taken if the client has specifically requested that certain information is to be disclosed before seeing me.

Case Notes

Case notes form part of my counselling service record to indicate that a session has taken place and give a general overview of what was covered in the session. They are an accurate and authentic brief summary of what was discussed. These notes are accessible to the client under my open access policy (see below). Only clinically relevant and meaningful objective information is entered in clinical records.

Audio/Visual Data

In some instances I may request for audio/visual data to be recorded of the counselling session e.g. during training or for use within supervision. In all instances the data would only be used for the stated purpose. Clients will be made aware of who will have access to and listen to the data. Written informed consent will be sought. Clients are free to decide whether to participate and they can change their mind at any time. The recording will be held securely whilst not in use. The client may have access to the data but this access cannot be extended to third parties without the explicit permission of the client. Data will be destroyed or removed immediately after the purpose of use has been completed.

Process Notes

These are the notes I might make to take to supervision or to engage in personal reflection on the therapeutic relationship. Process notes do not contain information that could be used to identify a client and are not part of the client record.

Supervision Notes

Clinical supervision is a professional requirement for counsellors. Supervision means that I meet regularly with another counsellor or psychotherapist who has supervisory experience to review my work with clients and discuss my professional development. Supervision is purposeful and remains confidential to the setting and context of the discussion avoiding identification of individuals. Any notes taken for supervision are limited to practice issues for reflection on supervision. They contain no personally identifiable information relevant to the client and as such do not form part of the client record.

Training

On occasion I will undertake further training which may require me to participate in supervision groups and/ or to write about my therapeutic work in assignments. Use of process material in these areas remains confidential to the setting and context of the discussion. It does not contain any personally identifiable information related to the client therefore any written material for training does not form part of the client record.

Storage and retention of Client Notes and Records :

Anonymised client notes are stored digitally on my passwork protected computer. Every client’s case notes are clearly marked with client’s case number. When the client completes counselling their file will be kept for 7 years and then destroyed.

Accessing Records

I operate an open access policy to clients who request to see their client record. Any client who wishes to access their record should let me know and I will endeavor to respond within 10 working days. A ‘client record’ comprises personal and tracking information, case notes and general correspondence. Client records may also include artefacts, completed assessment and evaluation forms, creative material carried out by the client. Anonymised process or supervision notes are not part of the client record.

Limits to Confidentiality

In certain instances there are legal obligations which must be adhered to which may require breach of confidentiality. Such circumstances will be communicated to clients at initial contact and may be referred to during the course of ongoing counselling if there is a likelihood of occurrence.

Court orders

I must respond fully to any Court order, including a citation to appear in court or to give a precognition statement or an order to recover documents.

Child Protection

I comply with Local Authority Guidelines for Child Protection which require me to break client confidentiality if I receive specific information concerning a child who is at risk because of physical, sexual or emotional abuse. Any action will be taken following discussion with the client and may include my supervisor. National Guidance for Child Protection (Scottish Government 2014 para 90) state that:

Information shared will be relevant, necessary and proportionate to the circumstances of the child, and limited to those who need to know. A record will be made of when it was shared, with whom, for what purpose, in what form and whether it was disclosed with or without informed consent.

Significant Harm and Life Threatening Situations

I have a duty of care to clients which means that in situations where I believe a client may cause significant harm to themselves or others, I have a duty to breach confidentiality and discuss the situation with others, i.e. health professionals, police and/or social work, where appropriate. I would always strive to inform the client that this action is being taken but this is not possible in all circumstances.

Road Traffic Act 1988 s 172

Information must be disclosed upon request by the police to permit identification of the driver of a vehicle involved in an offence. The client will be informed of the information disclosed.

Terrorism

There is no general duty to report crime. However, it is an offence not to report use or supply of money or property for terrorist activities (acts of serious violence, serious damage to property, danger to life, serious risk to health or safety of the public, or disruption of electronic systems, designed to influence government or intimidate the public for the purpose of advancing a political, religious, racial or ideological cause – Terrorism Act 2000). Legally if I receive such information I must contact the Police immediately without informing the source of information of this course of action, either before or after it has been taken.

Third Party Involvement

I will not disclose any information about a client to a third party without the written consent of the client unless required to by law as outlined above. When this agreement is sought, the written consent will identify how the information is communicated and for what purpose.

Any unanticipated communication with a third party will be reported to the client, together with the content, as soon as possible to minimise any distress and maintain trust in the relationship.