Annual Review of Mental Health Paperwork Matters (Even When Not Required)
The Problem With “Sign and Forget”
I’ve heard this many times: “My client is surprised by my cancellation policy and doesn’t want to pay for the missed appointment. I don’t understand. We reviewed the informed consent during our first session. We went over it together. I asked if they had questions, and they signed all the paperwork. Now they claim they don’t remember. What’s the problem?”
This moment perfectly captures the difference between having signed forms and maintaining informed consent. The problem wasn’t a lack of documentation. The therapist overlooked a critical reality: the first session is often the worst time for clients to absorb important information. The intake paperwork still needs to be signed on the first session but the problem makes sense.
During that initial meeting, clients are:
- Anxious about whether therapy will help
- Assessing whether they can trust a stranger with their deepest struggles
- Preoccupied with their own pain and concerns
- Simply trying to get started
In this heightened emotional state, they may nod politely while reviewing a consent form, but they’re not truly processing details about cancellation policies, confidentiality limits, or session frequency. They want help, and signing is the only way to start therapy. But genuine understanding often comes later, when a policy suddenly becomes personally relevant.
The Solution: Informed Consent as an Ongoing Conversation
Informed consent is not a one-time transaction. It’s an ongoing dialogue.
Annual review transforms paperwork from a bureaucratic checkbox into an opportunity for continuing conversation about expectations, boundaries, and the therapeutic relationship itself. It serves three critical purposes:
1. No Assumptions
Annual review shows that you do not assume understanding. Instead, you are actively confirming ongoing informed consent. What made sense to a client six months ago may feel different now. What they didn’t fully grasp initially might be crystal clear today. Or vice versa.
2. Legal and Professional Protection
If a complaint, audit, or dispute ever arises, your documentation should reflect that confidentiality, boundaries, financial expectations, and client rights and responsibilities were not just explained once but maintained over time and reviewed with the client.
3. Fosters Trust
Natural check-in points about the therapeutic relationship continue to build trust over time. It signals to clients: “Your understanding and agreement matter to me, not just at intake, but throughout our work together.”
What Professional Ethics Codes Actually Require
Here’s the interesting part: Most annual re-signing of paperwork is best practice rather than a hard legal requirement.
The NASW, APA, and AMHCA Codes of Ethics do not mandate annual re-signing of paperwork. All three codes leave it to professional judgment to determine when informed consent documents need to be updated or re-signed based on:
- Changes in services provided
- Changes in policies or procedures
- Changes in the client’s situation
- State licensing requirements
- Agency policies
- Third-party payer requirements
So why do it annually if it’s not required? Because policies change. Memory fades. Treatment evolves. Genuine informed consent requires us to keep pace with those changes and the client on board with them.
In light of paperwork changes…
⚠️ Important: February 16, 2026 Compliance Deadline
There’s a significant regulatory change coming that may require an annual review and re-signing of intake paperwork.
What’s Changing?
Earlier this year, the Department of Health and Human Services (HHS) updated the rules about how we protect substance use treatment information under 42 CFR Part 2. It’s called Part 2 – Confidentiality of Substance Use Disorder Patient Records. The new regulation applies to the records about drug and alcohol use and addiction, and counseling or therapy for substance use problems when treatment and records are associated with Federally funded SUDs programs.
The regulation is designed to reduce the barriers to treatment by
- having less red tape to navigate and
- strengthening confidentiality for “what’s written in the notes.”
“Part 2” refers to the section number within Title 42 of the Code of Federal Regulations that addresses confidentiality of substance use disorder patient records. It isn’t a sequence of related parts, and there isn’t a corresponding “Part 1” that applies.
The regulatory requirements are difficult for most therapists to understand without an interpreter. That’s why I spoke with Samantha Schalk, compliance strategist and founder of Guardian Clinical Essentials™.
What This Means for Your Practice
Samantha explained the basics of what we need to know now.
Simply receiving referrals from a federally funded SUD program does not, by itself, make a therapist subject to 42 CFR Part 2. Part 2 applies when a provider is operating as a Part 2 program or when they are handling records that originated from a Part 2 program.
Therapists can receive referrals from federally funded SUD programs without needing to change their documentation. Even when Part 2–protected records are received, the requirements apply to how those specific records are handled and redisclosed, not to the therapist’s documentation practices as a whole. Receiving Part 2 records does not convert a practice into a Part 2 program. Treating substance use as part of general mental health care does not automatically make a therapist or practice subject to Part 2. Federal assistance and program status are the determining factors.
- The update aligns Part 2 more closely with HIPAA by standardizing how disclosures and enforcement work, while still preserving heightened confidentiality protections for substance use disorder records. This change isn’t about adding new layers of protection, but about reducing administrative barriers and aligning how information can be shared appropriately, without removing core confidentiality safeguards.
- A single Part 2–compliant consent can allow information to be shared with a defined group of providers involved in a client’s care. Depending on how the consent is written, that group may include providers within the same program or across different agencies or independent practices, as long as the client has authorized it. What matters most is how the release is written. When a client authorizes a category of providers, the consent can support care coordination beyond one therapist or one organization.
- Require the following language on all disclosures: “42 CFR part 2 prohibits unauthorized use or disclosure of these records.”
- When a practice maintains Part 2–protected records, the HIPAA Notice of Privacy Practices must describe how those records may be used and disclosed under Part 2. This doesn’t apply universally. Many private practice clinicians won’t need to update their Notice of Privacy Practices unless they are actually subject to Part 2 or maintain Part 2–protected records.
How CFR Part 2 Affects Clinical Documentation
Compliance with Part 2 means we cannot “over-document.” In other words, we do not “tell the client’s story,” or provide unnecessary details. Instead, we write in general terms. We focus on facts, thoughts, feelings, and behaviors tied to the symptoms and treatment plan. Since most private practice therapists are hyper-aware of protecting client confidentiality, how we write notes will not be affected.
What Forms Are Affected?
- HIPAA: Notice of Privacy Practices
- Release of Information (ROI)
- Informed Consent
- Client Rights and Responsibilities
Where We Are Now:
Ideally, these forms should be updated by February 16, 2026.
However, HHS has not yet published standardized template language. Mental health providers are working to interpret the requirements and develop compliant language for their specific practices. Given this scenario, it’s likely that federally subsidized agencies are scrambling to get their paperwork updated by the February 16 deadline, but private practice therapists should have more time.
Documentation Wizard is actively working to determine language that meets the new Part 2 requirements and will make updated forms available as soon as we’re confident about what language to use. We are also working to determine how these updates affect specific clinical scenarios. We’re monitoring guidance and best practices closely to ensure our forms provide you with clear, compliant documentation with case examples to illustrate the issues.
For more information about these changes, see Guardian Clinical Essentials’ article on the February 2026 Substance Use Confidentiality Update.
Practical Guidance: What to Review and When
Beyond the February 2026 update, here’s your guide to ongoing paperwork review.
Review Annually (Best Practice):
HIPAA Notice of Privacy Practices
When nothing has changed, annual re-signing isn’t federally required. When there are material changes, it is required. (This year, the February 2026 update makes it required.)
Informed Consents, Disclosures and Practice Policies
Should be updated when there are material changes to treatment: new modalities, changes in fees or cancellation policies, different risks, updated telehealth policies, social media policies, etc.
Financial Responsibility/Payment Agreements
Annual signing isn’t legally required unless fees change or payment policies shift.
Required Annually (or More Often):
Release of Information (ROI) Forms
Many states and ethical guidelines recommend these expire after a specific period (commonly 90 days to one year) to ensure ongoing consent for sharing information. The client’s situation and wishes may change, so this is both legal protection and ethical practice.
Good Faith Estimate
This form is for private clients and must be signed every year.
✨Always check your state regulations and insurance company policies in case they mandate an annual review of paperwork.✨
How to Implement This With Your Clients
You don’t need to over-explain. Keep it simple and professional:
“Each year I ask clients to review and re-sign their paperwork, so everything stays clear and current.”
This one sentence communicates professionalism, care, and compliance.
The Documentation Wizard Bottom Line
Good documentation doesn’t rely on memory. It preserves clarity and protects the relationship. I know reviewing paperwork can feel like one more thing to add to the never-ending to-do list, but fulfilling legal requirements keeps you compliant. Best practices keep you protected.
We’re committed to providing you with forms that reflect current legal requirements and best practices. As we finalize compliant language for the February 2026 Part 2 requirements, we’ll make updated forms available.
In the meantime, remember that annual review remains a cornerstone of ethical practice. It’s not because regulations always demand it, but because genuine informed consent requires it.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms (in English and Spanish) are developed to meet strict Medicare requirements. Beth’s Documentation Wizard training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 2 attorneys, a bioethicist, and a billing expert and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.
