Writing counselling session notes is a key part of any School Counsellor's day. In this article we cover why you should write notes, common privacy questions and what a great school counselling session note looks like.
Why write counselling notes?
They help you prepare for your next session: A history of counselling sessions with a particular student can serve as a reminder when recapping before the next session.
Collaboration with your counselling team: If your school has multiple counsellors that are available on different days, having a history of the counselling sessions allows a different counsellor to see that student and to have a history of what was discussed previously.
Its required by your professional organisation: Taking session notes may required by your professional body. For example both the NZAC and the NZCCA Code of Ethics requires counsellors to keep documentation of counselling for the purposes of: enhancing counselling practice; and meeting the requirements of research, accountability, appraisal, audit and evaluation.
Auditing: Session notes can help prepare you for an Education Review Office audit
Collaboration with external support: In certain situations they could be used to facilitate liaison with external agencies as appropriate (e.g. Oranga Tamariki, SES, Health Services, Whanau, etc), always subject to the patient's consent.
Gaining insights and seeing trends: Collecting structured data about student sessions allows you to see trends within the school and to see if certain issues are becoming more prevalent.
Here are some handy sources on why school counsellors should keep session notes:
New Zealand Association of Counsellors (NZAC) - Code of Ethics
In section 5.7 "Documentation of Counselling" of the the NZAC Code of ethics the code requires the counsellor to keep adequate notes:
"Documentation in this code refers to all material about the client or about the counselling, recorded in any form (electronic, audio, visual and text). Documentation includes material collected for the purposes of: enhancing counselling practice; and meeting the requirements of research, accountability, appraisal, audit and evaluation.
(a) Counsellors shall maintain records in sufficient detail to track the sequence and nature of professional services provided. Such records shall be maintained in a manner consistent with ethical practice taking into account statutory, regulatory, agency or institutional requirements.
(b) Counsellors shall obtain informed consent from clients when writing reports for third parties.
(c) Counsellors shall keep records and notes secure. They shall create, maintain, transfer and arrange to destroy them in a manner compliant with the requirements of the confidentiality sections of this code.
(d) Counsellors shall inform clients of their right to access their documentation, to know how this information is being kept and to know who has access to it.
(e) Counsellors shall take all reasonable steps to ensure that documentation remains retrievable as long as is professionally prudent, or as is required by law.
(f) Counsellors are encouraged to ensure policies are in place for the safe and confidential storage and eventual destruction of client notes, in the event of the counsellor ceasing to practice, leaving the employing agency, or the counsellor dying."
NZ Post Primary Teachers’ Association (PPTA) - The School Guidance Counsellor
In the PPTA guide "The School Guidance Counsellor: Guidelines for Principals, Boards of Trustees, Teachers and Guidance Counsellors" the PPTA notes the following responsibility of the school counsellor:
"Keeps notes (when appropriate) securely, and of a sufficient standard to be useful and credible when referring to outside agencies, abuse disclosures, etc."
Christian counsellors association (NZCCA) - Code of Ethics
In section 1.9 "Record Keeping" of the the NZCCA Code of ethics the code requires the counsellor to sufficient records of their activities:
"Counsellors keep sufficient records of their activities in a secure manner in compliance with current professional health provider regulations (see the Health Information Privacy Code 1994 and its amendments) which state that client notes are to be kept for a minimum period of ten (10) years from the date of the last meeting with the client.
These records are kept:
1. for the counsellor’s own reference
2. to ensure that there is a record of the process undertaken
3. to enable the information to be presented clearly if required, for example, by a court of law."
How long do counselling notes have to be kept?
In New Zealand the Privacy Act of 2020 and the Health (Retention of Health Information) Regulations both apply to counselling notes, and all notes must be kept by the counsellor or agency for 10 years after the last contact with the client.
Who has access to school counselling notes?
School counselling notes are private and access is restricted to the counsellor. In some cases, at the counsellor's discretion, they may share a session notes with a colleague. This is usually done in the event that they both look after the same student. For more information about this topic, see the question below.
When can counselling notes be disclosed?
Disclosure to the student
In New Zealand, individuals have a right to ask for access to their own personal information. Generally, an organisation must provide access to the personal information it holds about someone if the person in question asks to see it. But remember, individuals can only ask for information about themselves.
The New Zealand Privacy Commissioner has put together a guideline on this particular topic, called Can I ask for notes taken in my counselling sessions? which states:
"Yes, you have the right under the Privacy Act (and the Health Information Privacy Code) to ask your counsellor or counselling service for your personal information (information that is about you), including personal and health information in your counselling notes. If you make a request for your personal information, the counsellor must respond to the request as soon as reasonably practicable and no later than 20 working days."
However there are some exceptions, for example a counsellor can withhold personal information (which includes counselling session notes) if disclosing it would pose a "serious threat" to someone's life, physical or mental health or safety or if the disclosure could prejudice physical or mental health. These exceptions are governed by the New Zealand Privacy Act's Principle 6 titled "Access to personal information". This principle states that people have a right to ask for access to their own personal information, but that there are exceptions to this rule as mentioned above.
Disclosure to other agencies involved in the student's care
Disclosing session notes is always something to take very seriously. The NZAC code of Ethics states in section "6. Confidentiality" that:
"6.1.a. Counsellors shall treat all communication between counsellor and client as confidential and privileged information, unless the client gives consent to particular information being disclosed."
"6.2.c. Exceptions to confidentiality occur when:
there is serious danger in the immediate or foreseeable future to the client or others,
the client’s competence to make a decision is impaired,
legal requirements demand that confidential material be revealed,
responding to a complaint about counselling practice."
For a more detailed discussion, see Counselling and the Law: A New Zealand Guide by Robert Ludbrook. This book is endorsed by the New Zealand Association of Counsellors Staff and covers the topic in far more detail.
In an article titled "Putting children first" the Privacy Commissioner has summarised some of the key issues involving the disclose of counselling notes to parents. The article discusses the fact that there will be some cases where information should be withheld from parents and that the improper release of counselling notes could be detrimental to a child’s wellbeing. They advise that "If you are in doubt as to whether release is in the best interests of the child, do not release the information." and that if you work in an agency (e.g. a school) its often best to ask for advice.
Before disclosing confidential session notes it's always a good idea to:
Make sure the notes being disclosed are relevant to the purpose of the disclosure request
Make sure you are certain of the identity of the individual the session notes are being disclosed to
Make sure the session notes are disclosed using a secure method of communication
What makes a good counselling note?
There are some requirements that good counselling session notes need to meet. A counselling note should typically include five parts:
The structured data section captures standard information about the session like who the counsellor is and who the student is.
The topic of the session (often called the classification). This is one of the most important fields since it is often used for reporting purposes to understand what trends are affecting the individual student and the school.
The unstructured session notes, these are free text paragraphs where the counsellor writes their observations, action Items and other text notes.
The answers to any questionnaires, for example the patient health questionnaire 9 (PHQ-9) which is often modified or adapted to be more appropriate for teens or adolescents or the General anxiety scale (GAD-7) questionnaire
Any attachments that are relevant to include with the session note
This section contains the Who, What and Where details of the counselling session:
The name of the counsellor conducting the session
The details of the student being counselled
The date the session was conducted
The duration of the session
The format of the session e.g. face to face, phone, chat, email
Referral details e.g. if the student was referred for a counselling session by a teacher
Topic of Session (classification)
This section contains the overall theme of the session. This is often referred to as the "classification" of the session. For example a counselling session could cover the topics of "Anxiety", "Bullying" or "Self Esteem". Certain classifications can include subclassifications, for example the classification "Anxiety" can include "Social Phobia", "Separation Anxiety" etc.
Counsellors can cover a variety of topics in a single session, therefore it's important to be able to include multiple classification or topics per session. These topics can then be used as a quick summary when reviewing the note in the future. Tracking the classifications of individual sessions also allows the counsellor to identify any trends affecting the student or the school. For example, a report showing how many counselling sessions cover, for example Anxiety within the Year 10 students, can give insight into whether anxiety is increasing as an issue at the school.
These notes are usually structured as free text and the contents and structure of these notes is up to the individual counsellor to decide. Common discussion points included in the session notes are:
Developments from previous sessions
Observations about the student
Review of the plan previously set in place
Details of the session
Safety of client