Frequently Asked Questions

How ethically set up a sliding fee scale so we are equitable with those seeking treatment? 

6.04     Fees and Financial Arrangements

(a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.

(b) Psychologists’ fee practices are consistent with the law.

The Ethical Principles do not dictate what is a fair charge for a session. In fact, there is even an ethical statement regarding bartering. A primary purpose of a sliding fee scale is to provide access to services for clients who may be less advantaged economically, either temporarily or permanently. A sliding scale should be developed based on specific criteria. Further, it should be applied fairly across all clients who are self-pay. The sliding scale should ideally be captured in writing and presented to clients who are eligible for the sliding scale at the initiation of treatment or if their circumstances change so that the sliding scale becomes appropriate.

My client’s insurance requires that she pay a $30 co-pay per session. She says she can’t pay the co-pay and wants me to accept the insurance payment of $60 per session as payment in full. Can I ethically do that? 

6.04      Fees and Financial Arrangements

(b) Psychologists’ fee practices are consistent with the law.

No. When working with an insurance company, therapists sign a contract noting that they will accept a certain fee. By not charging that amount of money you are breaking this contract and engaging in insurance fraud. Also, this would be a misrepresentation of your fees. You might be able to set up a payment plan with your client regarding when the co-pay is paid to provide your client with flexibility. You are also able to take on cases pro bono at your liking, which might be an option. 

My client of ten years sent me his wedding invitation. Is it ethical to go? Should I bring a gift? 

3.05      Multiple Relationships

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

4.01      Maintaining Confidentiality

Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.

It is likely that it would not be ethical to attend the wedding. Many dynamics could play out that might impact the therapeutic relationship dynamics and the consequences would be impossible to predict. Also, it is important not to create multiple relationships. In that case you would be holding the role of the therapist but also the role of a party go-er. In addition, this might be a breach of confidentiality as you will be exposed to the family and friends of the client and might be asked how you know the couple. Finally, a gift might be inappropriate depending on the context, cost, and significance. When giving a gift, it should have a therapeutic intent and impact. 

Scenario 1: A former client that you did psychological testing on contacts you and requests a copy of the psychological report and test data. 

Scenario 2: An attorney for a former client you assessed requests test data and materials from you.

The ethical standards relevant to this discussion include: 

• Standard 9.04 release of test data, standard 9.11 maintaining test security, Standard 9.10 explaining assessment results, 
• Standard 6.01 documentation of professional and scientific work and maintenance of records
• Standard 3.07, third-party requests for services 
• Standard 3.11 psychological services delivered to or through organizations, Standard 9.03 informed consent in assessments
• Standard 1.02 conflicts between ethics and law, regulations, or other governing legal authority
• Standard 4.0 5B, disclosures and HIPAA. 

There is a distinction between test data and test materials. Test data are raw and scaled scores, client/patient responses to test questions or stimuli, psychological reports, psychologist notes, and recordings concerning client/patient statements and behavior during an examination. Test materials consist of test manuals, protocols for administering or scoring responses and test items when they are included as part of the materials. When test materials include client/patient responses they are by definition treated as test data. Test results/reports must be reviewed with the client and can be released as they are deemed part of the client record. 

If test protocols allow, it is good practice to record client responses on a separate form from the test items. In most instances test materials that do not include client responses should never be released to clients or others unqualified to use the instruments. Similarly, unless recommended by a test developer, self-administered tests should not be given to clients to take home. This enables the psychologist to protect copyrighted test materials and prevent misuse.

Releasing test data to other health professionals poses an unreasonable burden on the psychologist and is not deemed feasible. Standard 9.04a does permit psychologists to withhold test data to protect the client or another individual from substantial harm. The psychologist should document the specific rationale for assuming that test data will be misused and consult with a lawyer.

HIPAA gives clients the right of access to inspect and receive copies of medical and billing records, chart notes, but not psychotherapy or process notes. In this instance chart notes must be separated from psychotherapy notes either electronically or physically by using separate folders within one or more secured filings cabinets that house the records. 

When responding to subpoenas for testing documents, psychologists should not provide any client records or information in response to a subpoena without the client’s written authorization or a court order. 

If test data are requested by a third-party, such as a court or government agency, the test subject is not viewed as the client and his or her right to obtain test information may be controlled by laws, regulations or contracts that differ from those in healthcare. A third-party does have a general right to receive at least the test report. If the court or attorney requests test materials, the psychologist can use a protective order to restrict release of test materials. 

If the testing is being performed as a condition of employment, the employer can require the prospective employee to sign away some or all of their HIPAA rights. Psychologists performing forensic and or neurophysiological assessments are referred to standards specific to these areas of practice.

My neighbor, whom I’ve known as a friend for years, wants me to start working with her daughter in therapy. I don’t really know the daughter. Is this a good idea? 

3.05     Multiple Relationships

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

4.01      Maintaining Confidentiality

Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.

Unless you live in an area where there is a shortage of therapists so that there are no other options available for therapy, it would not be a good idea to see the daughter. We put the interests of the client first. We avoid multiple relationships and we always maintain confidentiality. While we may take strong measures to maintain these standards, we still cannot control for the client’s perceptions. Would the daughter feel that she would have to hold back in revealing material for fear that the mother and therapist were talking behind her back? Would the daughter feel that she has to go along with the mother’s demands that she go into therapy … even if she doesn’t want to?

A better strategy would be to determine whether the daughter wants therapy or not. If she does, she should be part of the process of deciding who that therapist will be.

What are the ethical considerations involved in seeing or continuing to see clients through teletherapy? 

4.02     Discussing the Limits of Confidentiality

(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.

(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.

(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

4.03     Recording

Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all such persons or their legal representatives.

During the pandemic of 2020 – 2021, teletherapy became the standard. It is seen, after the pandemic, as a viable platform for psychotherapy. Many therapists and clients actually prefer doing therapy through a video platform. After all, they don’t have to get dressed, drive, park, wait, talk, drive, get home, and undress. And the video format for therapy occurs in situ.

There are drawbacks, however. One is that the insurance payor may reimburse at a lower rate for teletherapy (but, then, you may not have to pay for an office if you do teletherapy from a home office).

Also, some of the more familiar platforms like FaceTime or Google Duo fail the HIPAA test, so you would have to subscribe to a HIPAA-compliant service. There is also the possibility that the client could record the session so that the therapist loses control of confidentiality.

It is a good idea to have the client sign an ancillary Consent to Treatment form containing the following points:

• The form should point out that the therapist is not able to guarantee control over common computer issues like viruses, phishing, identity theft, or hacking. By signing the form the client acknowledges this reality.
• The form should say that the therapist may not be able to assess nonverbal cues accurately.
• There could be a technical glitch during a session, which would necessitate going to audio format.
• No images will be recorded by either the client or the therapist.

Click here to learn more about current Telehealth information from the CA Board.

What do you do about a records request for a client you haven’t seen in 6 years? 

6.01  Documentation of Professional and Scientific Work and Maintenance of Records

Under 6.01 of the APA Ethics Code (APA, 2010b), psychologists must create, maintain, disseminate, store, retain and dispose of records and data in a manner that enables the records to be used effectively and appropriately by the psychologist or others…[in order to] a) provide good care; b) provide for relevant supervision or training; c) ensure the continuity of care in the event of the treating psychologist’s injury or death; d) document decision-making; and e) allow the psychologist to answer any legal or regulatory complaint.

The time for record retention varies according to state law, Federal regulations, and institutional requirements; however, the APA Record Keeping Guidelines (2007) recommend that in the absence of legal requirements for record retention, the complete records should be retained for 7 years from the last date of treatment (for adults), and 3 years from the date a child has reached majority, whichever is later.

In this question, you can send any records (such as testing) which you feel are still relevant; however, you may want to specify anything which you feel is likely to be outdated.

My practice partner often comes to me to discuss her cases and wants my feedback. Based on her descriptions, I can recognize some of her clients at the office, and I wonder if we are HIPAA compliant. 

4.02 Discussing the Limits of Confidentiality(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.

(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.

(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

Clients in this small group practice should be aware that those who work in the office have access to their health information. Scheduling and coverage often involve the sharing of information that identifies a client. All staff, including the treatment providers, need to demonstrate formal training in HIPAA regulations. Everyone in a partnership needs to sign an employee confidentiality form that should be placed in their personnel file with a record about their completed HIPAA training.

It is difficult for members in a small partnership, including staff, not to be aware of each other's clients. Discussions among partners assist with reinforcing, integrating, and providing the necessary standard of practice. Respect for boundaries and confidentiality is a good discussion to have early in forming or joining a group.

In a small practice, usually, one of the partners oversees HIPAA authorizations, the maintenance of required records, staff training, privacy complaints, and mitigates the potentially harmful effects of privacy disclosures. If the information is kept private and confidentiality is preserved, the organization remains HIPAA compliant.

The APA Code of Ethics, 4.02 addresses the limits of confidentiality. The basis for this conversation appears to arise from standard 4.01, indicating that psychologists will take "reasonable precautions" to maintain confidentiality." The choice of the term "reasonable precautions" communicates the obligation to recognize both the responsibility and the type of appropriate measures that are necessary to protect confidentiality.

My client is in a crisis and needs more time. Am I ethically permitted to set limits and have times when I am not available? 

10.01 Informed Consent to Therapy

(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent , psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers.

The essence of the APA Ethical Code is to reinforce our treating others with respect and for us to be mindful of their legal rights. It is challenging to deal with a client in crisis. Here the ethical issue is to create a response plan that serves a client in trouble and is mindful of the practitioner's needs. There will be times when a psychologist is not able to respond immediately. Limits are essential for both a client and a service provider. Many psychologists in their outgoing messages inform others that if this is an immediate life-threatening emergency, that the client is instructed to call 911. In the summer of 2022, a new suicide prevention hotline of 988 will be rolled out in California and Nationwide. Ethical mistakes are often made when individuals feel that they are the only ones who can make a difference. That is why it is essential to provide other resources for clients who may be prone to a crisis when possible. Tools and resources may include everything from apps to the phone number of the Psychiatric Emergency Response Team. If providing more time is a reasonable accommodation, such as another session necessary for the client's mental health, the therapist must seriously consider if they have the time available. If not, they may need to find other resources if they know that their limited availability will not be enough to meet the demands of the client.

Treatment is best provided by practitioners who also attend to their wellness. Setting limits and having times when psychologists are unavailable supports the therapist's mental health.