Client Confidentiality

Welcome to Sojourner Recovery Services’ training on confidentiality policies.  Below you will find some general information on this subject as well as agency guidelines about how we disseminate information about our clients. This is not intended to be a comprehensive treatment of the topic and further training may be required.  If you have questions or concerns, please contact your supervisor or an administrator.

Counseling Definition of Confidentiality:

Confidentiality is the ethical responsibility of mental-health professionals to safeguard clients from unauthorized disclosures of information given in the therapeutic relationship. Siegeal (1979) defines it as follows: “Confidentiality involves professional ethics rather than any legalism and indicates an explicit promise or contract to reveal nothing about an individual except under conditions agreed to by the source or subject.”  According to Shah (1969, 1970), therapists have a moral, ethical, legal, and professional obligation not to divulge information without the client’s written consent.

According to the Ohio Chemical Dependency Professionals Board (2005):

The licensee or certificate holder shall be aware of and comply with all applicable state and federal guidelines, statutes and agency policies including, but not limited to confidentiality.

  Agency Policy Regarding Confidentiality

1. All staff shall not convey to a person outside of the program that a client attends or receives services from the program or disclose any information identifying a client as an alcohol or other drug services client unless:        

1.  the client consents in writing for the release of information
2.  the disclosure is allowed by a court order
3.  the disclosure is made to a qualified personnel for a medical emergency, or            
4.  research, audit or program evaluation purposes.      

2. The above records and information may be released only if prior written consent of the client or legal guardian is given.

Note:  “Authorization to Disclose Information” forms permitting release of information are included in the assessment process and the intake process.  As the client continues in treatment, additional agencies or individuals may request communication from the agency or the client may request that others be informed.  Additional releases may be completed and signed as needed.

3. Communication of such information is permitted among staff members of the program who have a need for such information as it relates to their job responsibilities.

Note: This does not allow asking about former clients, family members in treatment or friends from the recovery community.

4. When such a release is authorized by the client in writing, each page of the documents sent to any outside person or agency must include the following statements: “This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42CFR Part 2.  A general authorization for the release of medical or other information is not sufficient for this purpose.  The Federal rules restrict and use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The attached information is disclosed by Sojourner Recovery Services for the purpose requested and may not be used by the recipient for any other purpose or released to others”.         

Note: This statement is pre-printed on many of the forms used to send information.

5. Federal Law and regulations do not protect any threat to commit a crime, any information about a crime committed by a client either at the program or against any person who works for the program.  

Note: Should you be threatened or hear a client threaten another client or staff member or himself, contact your supervisor or the on-call person from your facility.   A call to an outside agency may be made without client approval.  

6. Federal Laws and Regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Note: Contact your supervisor to determine appropriate action in this case.

Confidentiality of client information is the basis for developing and maintaining a therapeutic relationship with our clients. In addition, confidentiality has become a legal principle that we must follow.

The best practice is to refuse to reveal a person’s presence in our programs or discuss any client with anyone else, until you are certain an authorization to release information exists for the person requesting information.

Completing Authorization to Disclose Information Forms

The proper completion of Authorizations to Disclose Information (“releases”) is among the most important tasks performed by Sojourner staff.  Authorizations to Disclose Information are legal documents that allow the agency to share protected information about our clients with other agencies and individuals in order to provide the best treatment.  An improperly completed Authorization to Disclose Information could result in legal action against the agency and its staff. 

No information, including whether or not a person is in treatment with us, is permitted to be given to anyone for whom the client has not signed an authorization.

Even if the caller or visitor “knows” the person is in treatment, we cannot confirm or deny knowledge of them, per federal confidentiality rules.

The following entries must appear on the Authorization form:

1. Client Name: Print client’s legal name.   

2. Date of Birth: Use number to coordinate with month, for example January would be 01.

3.  “Sojourner Recovery Services is authorized to:  (generally, we would check the box for “__ exchange information as noted with the following individual/ organization:______________________________________ ”)

Individuals or organizations we routinely ask clients to sign Authorizations for include, but are not limited to, the following:

A)   Personal physician

B)   Legal advisors and court officials, including probation and parole officers, including agency or court’s title as well as an individual.

C)   Family members.  Identify relationship in parenthesis, i.e., Judy Doe (mother).

D)    Referring agency, spelled out, i.e., Butler County Juvenile Court (not BCJC)

E)   Children’s Services

F)    All caseworkers involved with client or children

G)   Any person the client expects Sojourner Recovery to have contact with.       

4. Purpose of Disclosure:  This designates the reason for the release, which is depends upon the individual or agency the release is for.  Check the box marked “Coordinate treatment” for referral sources and collateral service providers.

You may also need to check the box marked “Other purposes”, specifying the       reason, such as “status and enrollment”, “to coordinate legal services”, “to coordinate medical services”, etc.    

5. Type of Information to be Disclosed:  this information will vary depending on whom the release is for. The type of information to be disclosed must be agreed upon by the client. At the box marked “Other”, we include “status and enrollment” which gives Sojourner permission to confirm that a client is enrolled in services, but not to disclose the client’s progress or any other information. This would allow us to take messages for a client who is receiving services. Otherwise we would have to inform the caller of our confidentiality statement.   

6. Amount of Information to be Disclosed:  If a client is authorizing release of information during the time the client is in treatment at Sojourner, the box to be checked is “information covering the most recent admission”.   

If a client is authorizing release of information about an admission prior to the current episode, check box for “information covering the previous three months”.

“Other amount of information” requires a specific period of time be designated, i.e., “previous twelve months”.

7. Signature of Client or Other Person Authorized to Permit Disclosure and Date: The signature of the client, [parent or guardian for clients under 18] is required in order to release the information. Also, please be sure the person signing is dating their signature.

8. Signature of Staff or Witness and Date: Include your name and credentials as well as the date signed.             

9. Revocation: The client has the right to revoke any release. Again, please be sure to include the date said client signs revocation.  Do NOT have the client sign this section unless it is to revoke the Authorization.

10.   Do not check all the boxes on the release!  This would render it invalid and any information given would violate federal law.

Quiz Instructions:

1. Click on the link below to access the quiz

2. Print the page

3. Complete the quiz

4. Submit the completed quiz to your supervisor

Client Confidentiality quiz