(1) A counselor providing professional services to a client or providing services billed to a third-party payor, must document services, except as provided in subsection (2) of this section. The documentation must include:

(a) Client name;

(b) The fee arrangement and record of payments;

(c) Dates counseling was received;

(d) Disclosure form, signed by counselor and client;

(e) The presenting problem(s), or purpose of counseling;

(f) Notation and results of formal consults, including information obtained from other persons or agencies through a release of information;

(g) Progress notes sufficient to support responsible clinical practice for the type of theoretical orientation/therapy the counselor uses.

(2) If a client requests that no treatment records be kept, and the counselor agrees to the request, the request must be in writing and only the following must be retained:

(a) Client name;

(b) Fee arrangement and record of payments;

(c) Dates counseling was received;

(d) Disclosure form, signed by counselor and client;

(e) Written request that no records be kept.

(3) The counselor may not agree to the request if maintaining records is required by other state or federal law.

(4) All records must be kept for a period of five years following the last visit. Within this five-year period, all records must be secured, with properly limited access.

Special provisions must be made for the retention or transferal of active or inactive records and for continuity of services in the event of a counselor's death, incapacitation, or cessation of practice. Such special provisions may be made by having another counselor review records with a client and recommend a course of action; or other appropriate means as determined by the counselor.

(5) After the five-year retention period, the counselor may dispose of the record. Disposal must be done in a secure and confidential manner that includes:

(a) Shredding;

(b) Deleting, erasing, or reformatting electronic media; and

(c) Other readable forms of media that are defaced or rendered unusable or unreadable.