How to Write Notes on Couples Counseling

Writing notes for couples counseling can be a lot more complicated than simply keeping a file for a single client. Psychologists are mandated to keep records of all clients for every session that occurs. Because of the strict code of confidentiality that a therapist must adhere to, it may be important to keep a separate file on each member of the couple. If the court requests a copy of one client's notes, the confidentiality of the other member could be compromised if they are not kept separate.

Things You'll Need

• 3 sets of notes
• 1 file
• Pen or word processing program

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Instructions

• 1

  Organize three sets of notes within one file for easy access. Label one set of notes with the first and last name of one member of the couple, and another set of notes with the first and last name of the second member. Label the third set of notes with simply the first names of both members of the couple. Mark the first two files as "Official" and the third as "Informal." For example, your three sets of notes may have the following labels: "Mike Moody - Official," "Janet Johnson - Official" and "Mike and Janet - Informal."

• 2

  Fill out the notes for the client who had more to work with that day first, following the session. Flip open to his set of notes and fill in all the necessary information, including the date and time of the session, the fee, his general mood and presenting problem, the services you delivered (what techniques you may have used), as well as any progress that was made. Make sure that you keep any information regarding his partner relatively limited. For example, you would want to leave out exactly what Mike's issue with his wife is if they include issues that may be relevant in court. This could break confidentiality if Mike's records are requested by the court and Janet's are not.

• 3

  Repeat the above step for the other client, making sure to include all relevant information for the client, while leaving out any serious information about her partner. If the partners are not paying from a joint account, make sure to keep track of how much each pays in your notes, as this could become a source of bickering for the two during therapy.

• 4

  In the third, informal file, feel free to write whatever you may need to remember for following sessions. Include the date of the session and then flesh out the more explicit issues the couple is coping with, as well as the dynamics of that day. For example, on May 23, Janet may have taken on the role of the pursuer while Mike played the role of distancer, yet on May 30 the couple may have traded roles. Pay attention to how the dynamics shift in order to see patterns.

• 5

  Keep these written notes in a fire- and water-safe filing cabinet that is securely locked. For electronic notes, make sure that your computer is password-protected and in a location where it is safe from theft. Remember that only the official notes may be requested by the court and that each client can only request his or her own file. Your informal notes are for your eyes alone, which should keep both you and your clients protected.