Counseling Records

This guide will help you gather the counseling/psychotherapy records needed for an aviation psychiatric evaluation. Use this as your personal checklist or, alternately, can give this to your therapist along with a signed records release from the therapist’s clinic.

RELEASE FORMS

Most clinics prefer that you use their own release forms. You may be able to download a form from the clinic website, if they have one, or you can call the clinic and ask about the records release procedure.

Please ask your therapist to send the records directly to my office. If a file instead comes to you by mistake, do not open the envelope but instead deliver it to me unopened. A broken seal on a records production taints the file and can require us to start over.

You should request the complete record of care, which includes ALL notes of these types:

  • Individual counseling notes, including psychotherapy notes
  • Psychological test results and reports, if any
  • Notes that include any and all information about the use of drugs or alcohol
  • Intake assessment notes

There are three ways to have the clinic send records to me. The preferred way is to have the file produced on paper and mailed to me. The mail always arrives and I can always read the pages.

The next best way is to have the therapist produce the records on a physical media. I can accept DVDs, CDs, or flash memory devices of all kinds. Files are occasionally corrupted, so I prefer paper, but this way usually works, too.

The third-best way to produce the file is by the therapist emailing the record to me. This would be the most efficient if it worked well, but security protocols may block the facility from sending a record or me receiving it. This can lead to a significant delay as I may have no no way of knowing when the record was  blocked or diverted.

Files CANNOT be faxed to me
. My server will block any fax more than a few pages and I will not know that the file has been blocked.

WHY DO WE NEED THE RECORDS, ISN’T A CLINICAL SUMMARY GOOD ENOUGH?

In the FAA Specification Sheet for a psychiatric examination, one of the core duties that the aviation psychiatrist must complete is

A review of all available records, including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, social worker, counselor, or neuropsychologist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders.

WHAT HIPAA SAYS ABOUT THERAPY NOTES

HIPAA rules gives special protections to psychotherapy records. Among the protections is that a therapist can refuse to release a psychotherapy file, without giving you a reason, unless a valid court order compels a release of the record.
To address a few common concerns you or your therapist might have, please know that:

  • The FAA advisory, stated above, specifically says that the psychiatrist must review treatment notes (not summaries) from your counseling provider.
  • A summary of treatment, whether by a letter or phone call, most of the time fails to meet the  “sufficient detail” standard as described in the FAA’s specification sheet.
  • A therapist’s summary letter, which by definition as a summary of a record, highlights some content and excludes other information, unwittingly places the therapist as a decision maker in a public safety assessment.
  • By contrast, releasing the file without restrictions keeps the responsibility for aeromedical safety assessments focused on the aviation psychiatrist.
  • The records have the same HIPAA psychotherapy protections when held in this office as when kept by the originator. The file can be released only with your written consent or a court order. If your therapist asks that I not release the file to you, in order to preserve the therapeutic alliance between you and your therapist, I have an ethical obligation to honor that request and would not release the file to you without a court order.
  • I also have an ethical obligation to de-identify my report so that the assessment does not reveal protected health information (PHI) of others. For example, I am not allowed to quote something from the psychotherapy record that inadvertently identifies any other person, such as a spouse, child, or companion.