Documentation for Collaterals

A collateral is identified as a person who is not a client but who may be allowed to attend a treatment session with the client if the client consents, or who may be allowed to confer with a therapist with client consent in order to receive information or to provide information concerning a client’s presenting problems.  Any information provided to the therapist by the collateral is confidential.  It is part of the client’s confidential treatment record.  If a therapist needs to disclose information provided by a collateral it is the client who could authorize that disclosure.  The confidentiality or therapist-client privilege relating to information provided to a therapist by a collateral belongs to the client, not the collateral.  This privilege can and should be explained to the collateral so there is no misunderstanding.  The therapist can use the Collateral Disclosure form (see below).

On occasion, therapists may meet with a collateral in order to determine if that individual is appropriate to participate in family therapy, couples counseling, or other treatment process.  Therapists should disclose to the collateral before any meeting or conference is held that they are not a counseling client and are not receiving treatment.  The Collateral Disclosure form, is designed for use by therapists to clarify the therapist’s role toward the collateral in order to avoid any misunderstanding.

It is important to stress to collaterals that any information they receive from the therapist or client is confidential treatment information and cannot be disclosed to any third party.

When a therapist is meeting with a collateral with client consent in order to obtain or share information with the individual, the therapist may bill for the time invested in meeting with a collateral using the appropriate Code of Procedural Terminology (such as CPT Code 90801), since meeting with collaterals can be an important part of the psychotherapy process.

Collateral Disclosure Form

1. As you know, I am providing services to a client, _________________________, who has authorized me to share information with you and to obtain information from you.  You are a “collateral” in the treatment process
2. You are not my client, and you will not be receiving treatment or services from me.
3. If you would like to receive counseling from a mental health professional, please let me know, and I will refer you to a therapist.
4. Any treatment information that I share with you is confidential.  You may not share that information with anyone else.
5. Any information that you share with me will be confidential, as part of my client’s treatment record, and I may share that information with my client.

I understand these disclosures and agree to comply with them.

___________________________________________            Date: ________________

Collateral

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