• Personal information – The client’s details, contact information, and treatment history.
• General health information – The client’s current physical health, sleep, lifestyle, and alcohol or substance use.
• Symptoms – The mental health issues requiring treatment.
• Family mental health history – Information on previous mental health diagnoses in the client’s family.
• Personal details – The client’s strengths, coping strategies, and therapy goals.
• Acknowledgment -The client’s signature, and if applicable, that of their guardian.

The HIPAA (Health Insurance Portability and Accountability Act) protects a client or patient’s information during intake and treatment.^[1] Certain exceptions apply, such as:

• If the patient consents to their information being shared.
• If the information is required for payments, treatments, and healthcare operations.
• If it is necessary for preventing harm to the patient or others.
• If disclosing the information is required to comply with a legal investigation.

Furthermore, the SAMHSA’s (Substance Abuse and Mental Health Services Administration) confidentiality regulations provide additional protections for a patient’s substance abuse records and treatment.^[2]