(1) A counselor providing professional services to a client or providing services billed to a third-party payee, must document services, except as provided in subsection (2) of this section. The documentation must include:
- (a) Client name;
- (b) The fee arrangement and record of payments;
- (c) Dates counseling was received;
- (d) Disclosure form, if required by WAC 246-810-031, signed by the counselor and client;
- (e) The presenting problem(s), or purpose of counseling;
- (f) Notation and results of formal consults, including information obtained from other persons or agencies through a release of information; and
- (g) Progress notes sufficient to support responsible clinical practice for the type of theoretical orientation or therapy the counselor uses.
(2) If a client requests that no treatment records be kept, and the counselor agrees to the request, the request must be in writing and only the following must be retained:
- (a) Client name;
- (b) Fee arrangement and record of payments;
- (c) Dates counseling was received;
- (d) Disclosure form, if required by WAC 246-810-031, signed by the counselor and client; and
- (e) Written request that no records be kept.
- (3) The counselor may not agree to the request if maintaining records is required by other state or federal law.
- (4) All records must be kept secured, with properly limited access.
- (5) All records must be kept for a period of six years following the last visit. For minor clients, records must be retained for six years after the date they turned 21 years old.
- (6) Special provisions must be made for the retention or transferal of active or inactive records and for continuity of services in the event of a counselor's death, incapacitation, or cessation of practice. Such special provisions may be made by having another counselor review records with a client and recommend a course of action; or other appropriate means as determined by the counselor.
(7) After the six-year retention period, the counselor may dispose of the record. Disposal must be done in a secure and confidential manner that includes:
- (a) Shredding;
- (b) Deleting, erasing, or reformatting electronic media; or
- (c) Rendering unusable or unreadable any other forms of media.
[Statutory Authority: RCW 18.19.050, 18.19.090, 18.19.020, 2021 c 170, 2023 c 425, and 2024 c 371. WSR 25-06-010, s 246-810-035, filed 2/20/25, effective 7/1/25. Statutory Authority: RCW 18.19.050 and chapter 18.19 RCW. WSR 09-15-041, § 246-810-035, filed 7/8/09, effective 7/8/09. Statutory Authority: RCW 18.19.050(1). WSR 97-17-113, § 246-810-035, filed 8/20/97, effective 9/20/97.]