3rd Edition

Record Keeping in Psychotherapy and Counseling
Ethics, Practice and Supervision

  • Available for pre-order. Item will ship after March 18, 2022
ISBN 9780367712518
March 18, 2022 Forthcoming by Routledge
320 Pages 21 B/W Illustrations

USD $56.95

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Book Description

Record Keeping in Psychotherapy and Counseling: Ethics, Practice and Supervision, grounded in contemporary challenges, emphasizes protecting the therapeutic and supervisory relationship through offering an essential framework for thoughtful record keeping within legal, ethical, supervisory and clinical contexts.

A reader-friendly conversational style plus compelling case examples from a variety of settings-- clinic to courtroom— bring dilemmas and strategies to life. New case studies invite readers to examine principles of ethical decision-making in order to reach sound decisions, meeting a critical need in training and continuing education. New material on telehealth and updated material on electronic records, the impact of digital communications, and experience implementing HIPAA, bring this book up to date. Sample forms for readers’ use and modification are available on the publisher's website.

Practitioners in all mental health disciplines, from students to seasoned clinicians, supervisors, and teachers will continue to rely on this book for protecting themselves, their patients, and their trainees.

Table of Contents

1. A Decade in the Making: Ethical Decision-Making, Record Keeping, and the Therapeutic Relationship in Extraordinary Times 2. Purposes of Clinical Records 3. Documenting Informed Consent 4. Characteristics and Contents of Good Records 5. Confidentiality 6. Exceptions to Confidentiality 7. Developing Policies and Procedures for Protecting Confidentiality and Managing Its Exceptions 8. Boundary Challenges: Impact of Digital Communication on the Therapeutic Relationship 9. Inactive Records: Access, Retention and Destruction 10. Using Patients’ Records as Therapeutic Tools 11. Clinical Supervision Records 12.Teaching Record Keeping 13. Sailing in Choppy Waters: Therapists Navigating the Legal System 14.Planning for Interruptions or Closures of Psychotherapy Practices 15. Case Studies for Reflection: Using Principles of Ethical Decision-Making.

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Ellen T. Luepker, MSW, BCD, is a licensed psychologist and clinical social worker in private practice and Psychiatry Instructor in the University of Minnesota Medical School. She was honored by the National Academy of Practice as a Distinguished Practitioner, by the National Association of Social Workers as a Social Work Pioneer, and received Smith College’s Day Garrett Award for her contributions to professional standards in mental health.


"This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues."

Judith Wallerstein, PhD, author, The Unexpected Legacy of Divorce, Second Chances, and What about the Kids?


"Ellen Luepker gives her readers the best of both worlds – a masterful synthesis of contemporary regulatory requirements grounded in clinical sensitivity and wisdom."

Jon G. Allen, PhD, senior staff psychologist, The Menninger Clinic; professor, Baylor College of Medicine, Texas, USA


"I have used the first edition for years to teach therapists and case managers the basics of good record keeping, and this new edition updates and adds depth…The chapter on ‘Teaching Record Keeping’ should be required reading for every social work and counseling school in the country. This is must reading for anyone who is called to court to testify or who wishes to become an expert witness or develop a forensic practice."

R. Keith Myers, LICSW, vice president, Clinical and Training Services, Wellspring Family Services; affiliate faculty, University of Washington School of Social Work, USA


"Ellen Luepker’s work provides a remarkably complete and readable volume on the current processes concerned with clinical record-keeping and confidentiality. Whether a student, teacher or clinician, this book is a must-have resource for practice information."

Barbara Berger, PhD, Institute for Clinical Social Work, Illinois, USA


"Rooted in 30 years of experience with patients, Ellen Luepker provides detailed practical guidelines and especially wonderful examples of how to keep written records that actually improve therapy and meet the requirements of the legal system. Practicing therapists will find [this] detailed guide to be one of the most useful books they read all year."

Thomas T. Frantz, PhD, Professor of Counseling Psychology, University at Buffalo, USA


"Ellen Luepker has finally made practical common sense out of the thicket of clinical, ethical, and legal requirements for record-keeping. For HIPAA implementation, this should be on the ‘must read’ list of every practitioner!"

Hubert H. Humphrey III, JD, former Minnesota Attorney General


"Record Keeping in Psychotherapy and Counseling was an invaluable resource to me as I launched a private practice. The success of this book is due to Ellen Luepker's dedication to ethical standards in patient care, coupled with her devotion to providing the highest level of clinical care. Ellen's book provides an opportunity for new and seasoned therapists to learn how to address challenging situations."

Kate Cosgriff, LCSW, PLLC, Durham, NC, USA


"This book deserves a place next to the DSM on every therapist’s reference shelf, the shelves of therapists of other treatment professions as well as those of social work clinicians. There are interesting case examples, and much of the text is written in easy-to-read conversational language. [It is] a 306-page, tightly packaged reference tome. The information is detailed and covers every area for which appropriate and adequate record-keeping is essential. Always with record-keeping as context, this work offers a richness of guidance and information in every area of treatment...a fascinating and credible resource for currently practicing psychotherapists. Using the typical on-line protocol for scoring the value of an item – one to five stars - I give this book a resounding ***** assessment."

Inge Oppenheimer, LCSW, BCD, American Association of Psychoanalysis in Clinical Social Work Newsletter