1. (1) Licensees must maintain the following records for each client:

   1. (a) an initial intake form which includes:

      1. (i) name of client;
      2. (ii) health history;
      3. (iii) current health status;
      4. (iv) consent of the client to treat;
      5. (v) date; and
      6. (vi) client signature; and

   2. (b) session notes, including:

      1. (i) date;
      2. (ii) services provided;
      3. (iii) comments from licensed therapist; and
      4. (iv) signature or initials of licensed therapist.
2. (2) Licensees must document in the client's records, at the time the initial intake form is required, if the client refuses to complete the client intake form.
3. (3) Licensees are required to maintain records for four years from the last date of service to the client.
4. (4) Any violation of this rule is considered unprofessional conduct.

Authorizing statute(s): 37-1-131, 37-1-136, 37-1-319, MCA

Implementing statute(s): 37-1-131, 37-1-136, 37-1-319, MCA

History: NEW, 2020 MAR p. 1327, Eff. 7/25/20.