(1) The licensed counselor or associate providing professional services to a client or providing services billed to a third-party payor, must document services, except as provided in subsection (2) of this section. The documentation includes:

(a) The following business information:

(i) Client name;

(ii) The fee arrangement and record of payments;

(iii) Dates counseling was received;

(iv) Disclosure statement, signed and dated by licensed counselor and client or associate and client on or before the initial session.

(b) The following treatment information:

(i) The presenting problem(s), purpose or diagnosis;

(ii) Notation and results of formal consults, including information obtained from other persons or agencies through a release of information;

(iii) Progress notes sufficient to support responsible clinical practice for the type of theoretical orientation/therapy the licensed counselor or associate uses; and

(iv) The associate must also provide all relevant information about their clinical work to the approved supervisor. This includes session notes, case discussions/analysis, or reports from collaborating professionals. The approved supervisor must have a thorough understanding of the clinical work that the associate is doing.

(2) If a client being treated by the licensed counselor requests in writing that no treatment records be kept, and the licensed counselor agrees to the request, then the licensed counselor must retain only the following documentation:

(a) The following business information:

(i) Client name;

(ii) The fee arrangement and record of payments;

(iii) Dates counseling was received; and

(iv) Disclosure statement, signed and dated by licensed counselor or associate and client.

(b) The client's written request that no treatment records be kept.

(3) The licensed counselor shall not agree to the request if maintaining client records is required by other state or federal law.

(4) The licensed counselor or associate or the associate's supervisor must keep all client records for a period of five years following the last visit. Within this five-year period, all records must be maintained safely, with properly limited access.

(5) The licensed counselor or associate or the associate's supervisor shall make provisions for retaining or transferring records in the event of going out of business, death or incapacitation. These provisions may be made in the practitioner's will, an office policy, or by ensuring another licensed counselor is available to review records with a client and recommend a course of action; or other appropriate means as determined by the licensed counselor or associate.