When a Client Wants SSI or SSDI
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.
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 Essential Clinical Forms help therapists create clear, clinically meaningful documentation that captures the thinking behind their clinical decisions without unnecessary detail. 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.
