Collateral Visit Agreements
Clinical Update April 2016
By Zur Institute
A collateral visit is when, besides your client and yourself, the clinician, you also see ‘collateral(s)’ in your office. Collaterals may include the patient’s parent/s, child, sibling, partner, colleague or friend.
The general goal of a collateral visit is to enhance the treatment by helping you get to know the collaterals’ thoughts, opinions, feelings, perceptions, etc. Watching the patient communicate directly with collatorals in the therapy room can also be helpful for therapists.
It is important to note that the collateral is NOT your client and generally is neither responsible for your fees nor has access to the records.
Collateral Visits — The Basics
- A collateral can attend a session with the therapist with or without the client present.
- Generally, unlike patients, collaterals do not have the right to access clinical records.
- Collaterals are not responsible for the fees of the sessions they attend, unless they have been responsible for the fees all along, as is often the case when the collateral is the parent of a minor patient.
- Collaterals are not your patients. You do not have the same responsibility for collaterals as you have for your patients.
- Information about the collateral may be entered into the clinical records with a varied range of details, depending on the clinician, the situation, the relationships between the patient and the collateral and the communication between the therapist, client and collateral.
- Clinicians who work with children often treat them in the context of their family. Sometimes family members are included in sessions as collaterals.
- If a clinician thinks it is appropriate, he/she may offer a referral to the collateral for a follow up with another mental health professional.
- Child or adult abuse and similar reporting laws are applied to collateral visits.
- In many situations, the patient is not mandated to sign an ‘Authorization to Release Information’ to the collateral for information shared during the visit if both collateral and patient are present in the room at the same time.
What should be included in a ‘Collateral Visit Agreement’?
- Explanation of what a Collateral Visit is and the role/s of collaterals in therapy.
- Confidentiality and privacy issues and limitation of confidentiality.
- Responsibility for fees.
- Clarification that the collateral is not a patient and is not the recipient of mental health services by the therapist during the visit.
- Who has access to the clinical records of the collateral visit(s).
- What may be included in the records of the collateral visit session.
Online Resources for Collateral Visits
- Collateral Visit Agreement form is provided in Zur Institute’s Essential Clinical Forms.
- CPH and Richard Lesely, J.D. on Confidentiality and Collateral Visits (scroll down to the Collateral Visit section)
- The Use of Collateral Sources in Forensic Evaluations: Part I