Geldard y Geldard, 2008, Cap. 23

Copyright 2008. Charles C Thomas. All rights reserved.
. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable
copyright law.
Chapter 23
KEEPING RECORDS OF
COUNSELING SESSIONS
any counselors, including ourselves, find the administrative and
clerical duties associated with counseling a chore. However, we
believe that it is generally in the clients best interests to keep detailed
and up-to-date records on each counseling session. All records should
be accurate, respectful of clients and colleagues and protected from
unauthorized disclosure. Practitioners should take into account their
responsibilities and the rights under data protection legislation and
any other legal requirements.
Ideally, report writing should be done immediately after the counseling session, while all the relevant information is fresh in the counselors mind, and before other inputs have had time to intrude.
In todays society we can either type, or dictate records using speech
recognition software, directly into a computer. Alternatively we can
keep handwritten records on printed forms or cards. Where records
are computerized adequate security measures are required to protect
client confidentiality. Similarly, handwritten records need to be kept in
secure locations (see Chapter 25).
Identifying the Client

Client records need to be clearly identified so that there can be no
confusion, because in large agencies it is not unusual to find two clients
with the same names. Identifiers might include:
1. clients family name (surname)
2. other names
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Personal Counseling Skills
3. date of birth (if known)

4. address
5. contact phone numbers
Where handwritten records are kept, it can be an advantage to label
each page of the client record with the clients full name so that the
possibility of pages being inadvertently placed in the wrong file is minimized.
Additional Demographic Information About the Client
Commonly, when the information is available, records may include
any of the following:
1.
2.
3.
4.
marital status
name of partner or spouse
names and ages of children
referral source
Notes About Each Counseling Session
The notes for each counseling session may include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
date of the session;

factual information given by the client;
details of the clients problems, issues or dilemmas;
notes on the process that occurred during the session;
notes on the outcome of the counseling session;
notes on interventions used by the counselor;
notes on any goals identified;
notes on any contract between client and counselor;
notes on matters to be considered at subsequent sessions;
notes on the counselors own feelings relating to the client and
the counseling process;
11. the counselors initials or signature.
We will now describe the content of the notes in more detail under
the headings listed above. However, although these headings are discussed individually, in practice, notes often flow together as the head-
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Keeping Records of Counseling Sessions
243
ings overlap. Hand-written notes should preferably be legible so that

if a client transfers to another counselor for some reason, notes can
easily be read, with the clients permission.
1. DATE OF THE SESSION
This heading is self-explanatory. When reviewing a clients progress
over time, its very useful to know the dates of counseling sessions.
2. FACTUAL INFORMATION GIVEN BY THE CLIENT
During a counseling session the client is likely to divulge factual information which may be useful in subsequent sessions. Sometimes small
facts which may appear to be insignificant provide the key to unlock a
closed door in the clients mind, or could, if remembered, provide the
counselor with a clearer picture of the clients background. An example of information that might be included in a counselors notes could
be:
The client has been married for 13 years and during that time left her husband
twice, once two years ago for a period of two weeks, and secondly six months
ago for a longer unspecified period. She has considerable financial resources,
lacks a social support system, had an affair some years ago and has kept this a
secret from her husband.
3. DETAILS OF THE CLIENTS PROBLEMS,
ISSUES OR DILEMMAS
Keep the record brief, so that it can be read quickly when required. An
example of this part of the record would be:
Mary suspects that her husband may be sexually involved with another woman,
is afraid to ask her husband whether this is so, and is confused about her attitudes to him. She cant decide whether to pluck up courage and confront him,
to leave him now, or to continue in what she experiences as an unsatisfactory
relationship with him. She is not willing to consider relationship counseling
with her husband.
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4. NOTES ON THE PROCESS THAT OCCURRED

DURING THE SESSION
The process is independent of the facts presented and of the clients
issues, and is concerned with what occurred during the counseling session, particularly in the client/counselor interaction. For example:
The client initially had difficulty talking freely, but as the counseling relationship developed he was able to explore his confusion and to look at his options.
Although he was unable to decide which option to pursue, he seemed pleased by
his ability to see his situation more clearly.
5. NOTES ON THE OUTCOME OF THE COUNSELING
SESSION
The outcome could be that a decision was made, or that the client
remained stuck, or that a dilemma was identified. Alternatively, the
outcome might be described in terms of the clients feelings at the end
of the session. Examples of notes under this heading are:
She decided to confront her husband.
She left feeling sad and determined.
She said that she could now see things clearly.
6. NOTES ON INTERVENTIONS USED BY THE
COUNSELOR
Notes under this section are intended to remind the counselor of particular interventions used. For example, the notes might say:
Taught relaxation.
Coached client in the use of assertive statements.
Discussed the anger control chart.
7. NOTES ON ANY GOALS IDENTIFIED
These may be goals for the client to achieve in the world outside, or
in counseling, for example:
The client wants to learn to be more assertive.
She wants to use the counseling process to sort out her confusion and make a
decision regarding her marriage.
She wants to experiment by taking risks.
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Keeping Records of Counseling Sessions
245
8. NOTES ON ANY CONTRACT BETWEEN CLIENT

AND COUNSELOR
It is important to remember any agreements that are made with
clients. These may be with regard to future counseling sessions, for
example:
The client contracted to come for counseling at fortnightly intervals for three sessions and then review progress.
It was agreed that counseling sessions would be used to explore the clients relationships with people of the opposite sex.
I have contracted to teach the client relaxation during the next session.
9. NOTES ON MATTERS TO BE CONSIDERED AT
SUBSEQUENT SESSIONS
Often during the last few minutes of a counseling session a client will
bring up an important matter that is causing pain and is difficult to talk
about. If this is noted in the record, then the counselor can remind the
client at the start of the next session, thus enabling the client to deal
with the issue in question, if they wish. Sometimes, as a counselor, you
will realize at the end of a session that aspects of the clients situation
need further exploration. It can be useful to make a note as a
reminder.
10. NOTES ON THE COUNSELORS OWN FEELINGS
RELATING TO THE CLIENT AND THE COUNSELING
PROCESS
These are required to help the counselor to avoid letting their own
feelings inappropriately interfere with the counseling process in future
sessions. Such notes can be invaluable in the counselors own supervision and may be useful in helping them to improve their understanding of the counseling process. An example is:
I felt angry when the client continually blamed others and failed to accept
responsibility for his own actions.
11. THE COUNSELORS INITIALS OR SIGNATURE
By initialing or signing case notes a counselor takes responsibility for
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what is written in them. In many agencies counselors work together

with other counseling team members. In such agencies, over a period
of time more than one counselor may see a particular client. Also, a
client may come back to an agency for further counseling after a particular counselor has left. In such situations it can be helpful to the
client if the clients counseling history is available, subject to the normal constraints of confidentiality.
As stated previously, writing records of counseling sessions can be a
chore. However, a counselor who does this diligently will quickly
become aware of the advantages. The effectiveness of future counseling sessions is likely to be improved if the counselor reads the clients
record before meeting with them each time. By doing this the counselor is able to tune in to the client right from the start of the interview and will not waste time on unnecessary repetition.
Clearly, records need to be detailed, accurate and legible if they are
to be maximally useful. However, when writing records, be aware of
the confidentiality issue (see Chapter 25) and of the possibility that the
legal system may demand that such records be made available to a
court. Also, bear in mind when writing records that clients may later
ask to read them. Clearly, clients have the right to read their own
records if they wish to do so.
LEARNING SUMMARY
Ideally report writing should be done immediately after a counseling session.

Records need to include:
- the date;
- factual information and details of the clients problems;
- notes on the process and outcome of the session;
- notes regarding interventions used, goals set, contracts made
and matters to be considered in the future; and
- notes regarding the counselors own feelings.
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Copyright 2008. Charles C Thomas. All rights reserved.

Identifying the Client

Personal Counseling Skills

3. date of birth (if known)

date of the session;

Keeping Records of Counseling Sessions

ings overlap. Hand-written notes should preferably be legible so that

Personal Counseling Skills

4. NOTES ON THE PROCESS THAT OCCURRED

Keeping Records of Counseling Sessions

8. NOTES ON ANY CONTRACT BETWEEN CLIENT

Personal Counseling Skills

what is written in them. In many agencies counselors work together

Ideally report writing should be done immediately after a counseling session.

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