Confidentiality, Records and Disclosure

The Therapeutic Record in Couples Therapy

When I provide couples therapy, I maintain one joint clinical record for the couple. This record documents the couples therapy service and may contain information provided by either partner, information discussed jointly, clinical observations, assessments, interventions, treatment planning, and other information relevant to the couples therapy.

Both partners are considered participants in the couples therapy service, and both will be informed at the beginning of treatment about the nature of the joint record and the implications for confidentiality and disclosure.

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At times, an individual meeting with one partner may be clinically appropriate as part of the couples therapy process. For example, individual meetings may occur during an initial couples assessment or when additional information is needed to understand the couple's circumstances.

When an individual meeting occurs as part of the couples therapy process, it remains part of the joint couples record. It does not create a separate individual clinical record or automatically establish individual confidentiality from the other partner.

Before such a meeting, I will clarify the purpose of the meeting and the applicable confidentiality expectations.

Clients should therefore not assume that information shared during an individual meeting that is part of couples therapy will automatically remain exclusively accessible to that individual.

Separate individual therapy

If a partner engages me for individual therapy that is separate from the couples therapy service, a separate individual clinical record will be maintained for that service.

The individual service and the couples service are distinct therapeutic relationships and records. The confidentiality arrangements applicable to the individual service will be explained when that service is established.

Information from a separate individual therapy record will not automatically become part of the couples record or be disclosed to the other partner.

If information needs to be shared between separate individual therapy and couples therapy, the appropriate consent and disclosure requirements will apply, subject to any applicable legal or professional exceptions.

Confidentiality in Couples Therapy

Confidentiality remains an important part of couples therapy. However, confidentiality in couples work has additional considerations because information disclosed by one partner may affect, or be relevant to, the other partner and the therapeutic relationship.

By reviewing this policy as requested before starting couples therapy, both partners are informed that:

• the couples therapy is documented in one joint clinical record;

• information shared during couples therapy may become part of that joint record;

• information shared during an individual appointment that forms part of the couples therapy process is also documented within the joint couples record;

• a joint couples record may contain personal information about both partners;

• information disclosed during a joint session cannot necessarily be treated as information belonging exclusively to the person who disclosed it;

• information may be disclosed outside the therapeutic relationship only with appropriate consent, unless disclosure is authorized or required by law; and

• clinical records may be subject to access rights, legal processes, or other requirements established by applicable legislation.

Clients are encouraged to discuss any concerns about confidentiality before sharing information that they consider particularly sensitive.

Clinical Documentation and Requests for Records

I maintain clinical documentation that is relevant to the services provided. Documentation is intended to accurately and impartially reflect the therapeutic work, relevant clinical information, professional observations, assessments, interventions, and significant communications.

Documentation will be limited to information that is relevant to the provision of service and professional or legal requirements. The clinical record will not be used as a forum for advocacy for one partner or to establish one partner's version of disputed events as fact without appropriate clinical or evidentiary basis.

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When documenting information provided by a client, I will distinguish, where clinically relevant, between information reported by the client and my own professional observations or assessments.

Requests for Records or Information by One Partner

Because couples therapy is documented in a joint clinical record, a request by one partner for access to or disclosure of the record will be considered in light of the privacy interests of both partners.

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A request from one partner does not automatically mean that all information in the joint record can be released to that partner or to a third party on that partner's behalf.

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When a request is received, I will consider:

• the nature of the therapeutic service;

• what information is being requested;

• whether the information concerns one partner, both partners, or the couple's therapeutic work;

• the privacy and confidentiality interests of the other partner;

• whether appropriate consent has been provided;

• whether third-party information is contained in the requested material;

• whether applicable legislation establishes a right of access or governs disclosure;

• whether disclosure is authorized or required by law; and

• whether professional, legal, or regulatory consultation is appropriate.

Where appropriate and legally permitted, information relating to another person may be withheld or redacted.

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Requests for Letters, Summaries, or Confirmation of Information

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A partner may request a letter, treatment summary, confirmation of attendance, or other documentation following or during couples therapy.

Such requests will be considered in light of the fact that the couples service is documented in a joint record.

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Where appropriate, I may provide a factual document limited to information that can properly be disclosed. For example, depending on the circumstances, this may include confirmation of dates of service, attendance, the nature of the service provided, or information that an individual personally disclosed during treatment.

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A requested letter will not automatically be written in the form requested by a client. I will not provide unsupported opinions, advocate for one partner in a dispute, or characterize disputed events as established facts when they have not been independently assessed or verified.

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Where a requested document is likely to be used in legal, administrative, employment, insurance, or other adversarial proceedings, I may limit the information provided or recommend that the appropriate legal or administrative process be used to obtain relevant documentation.

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Information Shared During an Individual Appointment That Is Part of Couples Therapy

If one partner meets with me individually as part of the couples therapy process, I will clarify that the appointment is part of the couples service and that the information may form part of the joint couples record.

The fact that the other partner is not present does not, by itself, establish that the information is subject to a separate individual record or an expectation that it will never be disclosed to the other partner.

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Where clinically appropriate, I may encourage the client to bring relevant information into the joint therapeutic process.

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There may be circumstances involving safety, risk, legal obligations, or other professional considerations in which the handling of information requires additional care. These circumstances will be considered on a case-by-case basis.

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Separate Individual Therapy

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When I provide individual therapy to a person who is not receiving that service as part of couples therapy, a separate individual clinical record is maintained.

Information contained in a separate individual therapy record will not automatically be incorporated into the couple's record or disclosed to the person's partner.

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If a client wishes information from individual therapy to be shared with their partner or incorporated into couples therapy, appropriate consent will generally be required.

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The existence of separate individual therapy does not, however, prevent disclosure where disclosure is otherwise authorized or required by law.

Consent to Release Information

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When information is to be disclosed to a third party, informed consent will generally be obtained from the person or persons whose information is being disclosed, unless disclosure is otherwise permitted or required by law.

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Consent should identify, as appropriate:

• what information is being disclosed;

• the purpose of the disclosure;

• who will receive the information;

• the method of disclosure; and

• any relevant limits on the disclosure.

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Where the requested information concerns both partners or the couple's joint therapeutic work, I may require consent from both partners before releasing information to a third party.

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I will not assume that consent provided by one partner authorizes disclosure of the other partner's personal information.

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When One Partner Wants Information Shared and the Other Does Not

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If one partner requests disclosure of information from couples therapy and the other partner does not consent, I will not simply treat the first partner's request as authorization to release the entire joint couples record.

I will assess the request in light of the nature of the record, applicable privacy legislation, the rights and privacy interests of both partners, and any applicable legal authority.

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I will consider:

1. What information is being requested?

2. Does it concern one partner, both partners, or the couples therapy as a whole?

3. Is the information contained in the joint couples record or a separate individual record?

4. Does the requesting partner have a legally established right of access?

5. Does disclosure engage the privacy interests of the other partner or another third party?

6. Is consent from one or both partners required?

7. Is disclosure authorized or required by law?

8. Would redaction or partial disclosure be appropriate?

9. Is professional or legal consultation required?

The fact that one partner wants information disclosed does not, by itself, establish that the other partner has consented to disclosure of their personal information.

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Conversely, the fact that one partner objects to disclosure does not necessarily eliminate a legally established right of access. Requests will therefore be assessed individually rather than according to an automatic rule.

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Third-Party Requests

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Requests for records or information from lawyers, insurers, employers, government agencies, health-care providers, courts, or other third parties will be considered separately from a client's request for access to their own information.

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Information will not be released simply because a third party requests it. Appropriate consent, legal authority, or another lawful basis for disclosure will be considered before information is released.

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Where disclosure is authorized or required, only information that is relevant and necessary for the stated purpose will generally be disclosed.

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Legal Requests, Subpoenas and Court Orders

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Clinical records may be subject to legal processes, including subpoenas, court orders, or other lawful requests for information.

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If I receive such a request, I will review the nature and scope of the request and, where appropriate, seek professional, legal, or regulatory consultation.

I will take reasonable steps to protect confidential information and avoid disclosing information beyond what is legally required or authorized.

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Where permitted and appropriate, clients may be informed of a legal request and its potential implications.

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Safety and Other Legal Exceptions to Confidentiality

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Confidentiality is subject to limits established by law and professional standards. Information may be disclosed without a client's consent where disclosure is required or authorized by applicable law, court order, or where applicable professional or legal requirements relating to safety or risk require or permit disclosure.

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Where disclosure without consent is permitted or required, I will seek to disclose only the information necessary for the relevant purpose.

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Access to Records

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Clients may have rights of access to their official social work records subject to applicable legislation and professional requirements.

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In couples therapy, the record is a joint clinical record and may contain personal information about both partners. Access to the record therefore requires consideration of the privacy and confidentiality interests of both partners and any third parties identified in the record.

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Where necessary and legally appropriate, information relating to another person may be masked or redacted.

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Requests for access, correction, or review of records will be addressed in accordance with applicable legislation and professional requirements.

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Couples Therapy and Legal or Relationship Conflict

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Couples therapy is intended to provide a therapeutic setting for relationship work. It is not a forensic investigation or a process for determining which partner is truthful in a disputed relationship history.

When significant allegations, legal proceedings, or other adversarial processes arise, I may recommend that clients obtain independent legal advice or seek an appropriately qualified professional for an assessment outside the therapeutic relationship.

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I will maintain the distinction between:

• information reported by a client;

• information documented in the clinical record;

• my direct clinical observations;

• professional clinical opinions supported by assessment; and

• facts independently established through another process.

This distinction is particularly important when clinical documentation may later be used outside the therapeutic setting.