Records & Clinical Notes
Records & Clinical Notes
This document explains how SILZ Counselling & Psychotherapy (SILZ) creates, stores, uses, and protects client records and clinical notes. It is designed to reflect best-practice expectations for ethical counselling and psychotherapy practice in Australia, including professional obligations commonly associated with counselling and psychotherapy best practice.
Purpose
To support safe, effective, and ethical care
To protect client privacy and confidentiality
To clarify what records are kept, how they are used, and how clients can request access
What records SILZ keeps
Client contact details and basic identifying information
Intake information and consent forms
Appointment records (dates, attendance, cancellations)
Clinical notes (brief progress notes and relevant clinical observations)
Risk and safety documentation where relevant
Correspondence relevant to your care (e.g., with your consent, communication with a GP or other treating professional)
Copies of letters or reports prepared at your request (where within scope)
Administrative and financial records (invoices, receipts, payments)
Clinical notes: style and limits
Notes are kept brief, relevant, and professional.
SILZ aims to record information that supports continuity of care, clinical reasoning, and risk management.
Notes are not a transcript of sessions and may not include every detail discussed.
SILZ keeps records electronically
Reasonable steps are taken to protect records from loss, misuse, unauthorised access, modification, or disclosure.
Access to records is restricted to the practitioner and, where applicable, authorised professional supports directly involved in practice administration (e.g., secure software providers), subject to confidentiality and privacy obligations.
Confidentiality and use of records
Your records are used for purposes directly related to providing counselling/psychotherapy services, including:
Planning and delivering your care
Maintaining continuity and quality of service
Meeting ethical, professional, and legal obligations
Invoicing and practice administration
SILZ does not share your information without your consent except where required or permitted by law, or where there is a serious and immediate safety concern. See also Privacy, Confidentiality & It's Limits
Sharing information with third parties
With your consent, SILZ may share relevant information with:
Your GP
Psychologists/psychiatrists
Other allied health professionals
Your EAP (where applicable and within the limits of the EAP arrangement)
Information shared is limited to what is reasonably necessary for the purpose.
There are circumstances where SILZ may need to disclose information without consent, including:
If required by law (e.g., a valid subpoena, court order, or other lawful requirement)
If there is a serious and imminent risk to your safety or the safety of another person
If disclosure is necessary to prevent or lessen a serious threat to life, health, or safety
If there is a legal obligation relating to child safety or other mandatory reporting requirements
Where possible and appropriate, SILZ will discuss any required disclosure with you.
Session recordings
SILZ does not routinely record sessions.
Sessions may be recorded only with your explicit, informed consent.
If a recording is made, SILZ will clarify:
the purpose of the recording
how it will be stored and secured
who will have access
how long it will be retained
how it will be deleted or destroyed
You can decline recording without it affecting your access to counselling.
To help maintain privacy and trust, please do not audio-record, video-record or use automated transcription during sessions without prior consent from your SILZ counsellor and everyone participating. If a recording would support your accessibility needs or help you remember our discussion, please talk with your counsellor beforehand so we can agree on a suitable approach.
Access to your records
You may request access to your records. See more information outlined in Your Rights.
Corrections
If you believe information in your records is inaccurate, incomplete, or out of date, you can request a correction.
SILZ will consider your request and, where appropriate, update the record.
If a record cannot be altered (for clinical integrity or legal reasons), SILZ may add a note to reflect your requested correction.
Retention and disposal of records (minimum timeframes)
SILZ retains records in line with professional and legal expectations.
Minimum retention period: SILZ will keep client records for at least 7 years from the date of the last contact.
If you were under 18 at the time of service: SILZ will keep records for at least 7 years after you turn 18.
After the minimum retention period, records may be securely deleted or destroyed.
Data breaches
If SILZ becomes aware of a privacy breach that may result in serious harm, SILZ will take reasonable steps to:
contain and assess the breach
notify affected individuals where appropriate
comply with any applicable notification obligations
review practice systems to reduce future risk
Privacy and handling of personal information
SILZ Counselling & Psychotherapy is committed to protecting your privacy. Personal information (including health information) is collected and held only where it is reasonably necessary to provide counselling/psychotherapy services, manage appointments and billing, and meet ethical and legal obligations.
SILZ takes reasonable steps to keep your information secure, including using electronic record-keeping systems with access controls and secure storage. Information is not shared with third parties without your consent, except where required or permitted by law (for example, a valid subpoena/court order) or where disclosure is necessary to prevent or lessen a serious threat to life, health, or safety.
You can request access to, or correction of, your personal information by contacting hello@silzcounselling.com.au.
This document may be updated from time to time. The version published on the SILZ website is the most current.