A therapist recently asked me how to handle a request from the Social Security Administration for the medical records of a client she hadn’t seen in several months and only for two sessions. The request was accompanied by a signed release so it was legitimate.
Not having access to the client’s medical record could be problematic if this therapist is audited. But the real issue at this moment is whether this therapist is truly qualified to comment on this client’s ability or inability to work having seen her only two times and not recently.
When my supervisees face this situation I tell them that the client needs to be seen at least six times before an assessment can be made so that professional integrity is maintained. This stand can sound harsh to people who need aid and have no other place to turn. But the recommendation is not about refusing to write the letter or complete the form. It’s about having no useful information.
The SSI and SSDI forms are extensive requiring specific answers that in my experience, are not provided in the first two sessions. It can take me up to two sessions just to complete a form properly let alone do an Intake Session.
The good news is that the discussion about the client’s level of ability to perform tasks of daily living can provide a lot of good information for the therapeutic process itself.