Gerry Grossman practice Exams

What is the order of treatment?

1. Safety

2. Legal & Ethical obligations

3. Assessment

4. Diagnosis/develop treatment plan

5. Treat

If you're stuck between two good options, consider:

- category of response

- order

- evidence in support

**answer the specific question being asked, based solely on the information at hand, as If you were a generic therapist

What are the legally required disclosures at the beginning of therapy?

Licensure/registration tatus

BBS complaint process

Use of Telehealth

Privacy policy (if a HIPAA covered entity)

Fee and how fee was computed

Good faith estimate

Laws about informed consent

Anyone being treated via Telehealth must give specific Telehealth consent

Exceptions to informed consent

emergency situations (rare)

(c) Upon initiation of telehealth services, a licensee or registrant shall do the following:

Obtain informed consent from the client consistent with Section 2290.5 of the Code.

178

- inform clt that Telehealth will be used

- inform of risks and limitations

- inform of licensure

- gather and document specific consent for Telehealth (doesn't need to be in writing, can be verbal)

-

Who can provide consent for a minor

-parent/legal guardian

- another adult/relative living in same household with a Caregiver Authorization Affidavit

- Minor 12/+ can independently consent (if mature enough to participate intelligently in treatment)

If a Minor (12 or older) independently consents for treatment what mustt you do?

Contact the parents or reason for not contacting must be documented

Can parents be forced to pay for treatment they did not consent to?

No

What happens if one parents consents for treatment and another parent objects (both have legal custody) are you legally able to continue treatment?

Legally, Yes (unless the other parent legally has veto power, which is rare)

Clinically, you should consider if it's worth it to the child/how it will impact treatment.

At what ages can a minor not be involuntarily hospitalized alongside adults?

Under 16 cannot be involuntarily hospitalized alongside adults

Can parents who consented for minor's treatment request records?

Yes, but:

Can object if you believe the release would be harmful to the minor or the relationship with the minor

if they want to appeal, they can have 3rd party clinician (of their choosing) review and determine if records should be released

Do parents have rights to records for treatment that they did NOT consent to?

No, you cannot unless a minor agrees to release records

Who is responsible for payment if parents consent to treatment of a minor?

parents

Who needs to consent for release of records to 3rd party (i.e. insurance)

All participating family members who COULD have consented (even if they didn't)

Can minor consenting on their own to treatment still use parents insurance?

Yes but could expose some info about treatment to parents

Who must consent to the release of records in couple or family therapy?

All participants who consented to treatment

5 major exceptions to confidentiality

- suspected child abuse

- suspected elder or dependent adult abuse

- danger to self

- danger to others

- legal authorization (ROI, court order)

If you must break confidentiality

- share minimum information necessary

- document disclosure and reason

- not legally obligated to inform clients (but it's good practice if appropriate)

If you legally CAN break confidentiality but are not mandated

err on the side of maintaining confidentiality (per ethics code)

Privileged information

Kinds of information that can come out in court proceeding

Holder of privilege

generally the client, even if a minor

When might a Judge block someone from waiving privilege

(particularly a minor) if judge believes not in best interest

Who can make the decision to waive privilege?

- The holder of privilege

- judge can claim exception to privilege

NEVER the therapist

When can you give records or info to court proceeding?

if client waives privilege or judge determines there is an exception to privilege

If a subpoena comes from an attorney, should you treat it as a request or a mandate?

request

If a subpoena comes from a judge, should you treat it as a request or a mandate?

mandate

Can you ignore a subpoena?

No, you must respond

Steps to take if you receive a subpoena

1) contact attorney

2) assess for source and validity

3) contact client to determine wishes

4) assert privilege unless client waives or judge has already determined exception to privilege applies

If you receive a subpoena and are unable to reach the client or the client is unsure what to do, what should you do?

best default is to claim privilege on behalf of client

Who owns client records?

Property of the practice owner (i.e. clinic, hospital, practice, supervisor/employer)

If a client has made a written request to inspect records, how many days do you have?

5 days

If a client has made a written request for a treatment summary, how long do you have?

10 days, unless extensive records more time

If a client has made a written request for a copy of their records, how long do you have?

15 days

If you believe releasing records to client would be harmful

- can refuse

- document reason for refusal

- inform clients of right to appeal

How would a client appeal a therapist's refusal to release records?

Can have a 3rd party clinician of their choice review the records who will make final determination

If a client wants to make a change to their record, what can they do?

- Can add a short statement to their file

- Cannot alter existing records

Can you release records to a 3rd party?

Yes, if provided legal authorization (ROI) from all participants in therapy who could have consented to treatment (i.e. a minor who participated but parents consented on their behalf)

Some instances when authorization is not required

When is specific authorization NOT legally required to release records?

When communicating with another active treatment provider, for the purpose of diagnosis or treatment planning

Info required for billing (ie. insurance)

(Can be helpful if cat is hospitalized)

Requirements for ESA letter

at least 30-day clinical relationship with client

Inform clt that presenting ESA as service animal is a crime

What specific protections did CA add in 2024 for records?

Records of abortion and related services

Gender-affirming care

What must you do at first instance of Telehealth?

- get specific consent for Telehealth

- provide license/registration info

- inform risks and limitations

- document reasonable efforts made to locate crisis resources local to the client (not necessary if low risk)

At each instance of Telehealth what must you do?

Verbally obtain and document the client's legal name and current location

assess appropriateness of Telehealth (privacy/confidentiality, symptoms)

follow best practices for security and confidentiality

If your client goes out of state on a temporary basis, what are your options?

some states have temporary carve-outs in their laws

some states may grant exceptions if you request with the other state's board

Must have clear legal authorization

May still maintain contact, can assist with crisis

What specific steps do HIPAA providers have to take to safeguard PHI?

Notice of privacy practices

- designate a privacy official

- inform clients/staff of privacy policies/procedures

- disciplining stand who violate rules

- repair harmful effects

- safeguards against release of private information

- complaint procedures for violations

- ensure confidentiality of electronic health info

- protect against threats to info security

- notify HHS of breaches to security

- get client permission before communicating via unsecured email

Psychotherapy notes cannot include

- session start/end times

- diagnosis

- progress

- tx plans

- symptoms

- interventions

- prognosis

Elder is defined as

Anyone who is 65 years or older and resides in CA

Do elders and dependent adults have to reside in CA?

Yes

Anyone at an inpatient 24-hour health facility qualifies as:

a dependent adult

Types of elder abuse

- physical abuse

- financial abuse

- abduction

- isolation

- abandonment

- neglect/self-neglect

(permissive report for other types)

Elders - Physical abuse

sexual abuse, intentional over- or under-medication

Elders - Financial abuse

someone is exploiting them to steal resources

abusing authority or position of trust

Elders - Abduction

Where person is taken outside of CA, or prevented from returning, against their will

Elders - Isolation

Being denied contacts with others and it is not medically indicated

Elders - Abandonment

caretaker deserts patient when a reasonable person would not have done that

(of transporting them across town and the elder physically attacks them, if the caretaker takes distance that's not abandonment)

Elders - Neglect (including self-neglect)

basic needs are being neglected by caregivers

OR

struggling to take care of self in basic, fundamental ways

Elder abuse - permissive reporting

Can report any other form of abuse we believe is abuse and doesn't fit into a category

(NOT a requirement)

If you hear of elder abuse directly from victim, you must report unless ALL of these apply:

- person has been diagnosed with mental illness (i.e. cognitive impairment, reality testing)

- Not aware of any supporting evidence (if unclear, must report)

- reasonably believe abuse did not occur

Signs of physical abuse - Elders

- unexplained injuries/bruising

- broken bones, sprains, etc.

- STIs

- medication under- or over-dosing

Signs of abandonment/neglect - Elders

-unusual weight loss

- poor nutrition/dehydration

- poor hygiene

-unsanitary/unsafe living environment

- inappropriate clothing

- lack of necessary medical aid (i.e. glasses, hearing aids)

Signs of financial abuse - Elders

- sudden change in financial status

- unpaid bills when person has money to pay them

- valuable items/cash missing

-unusual/impossible financial activity

- sudden appearance of unnecessary goods/services

- signatures on checks don't match

Timeframe for reporting elder/dependent adult abuse (if not in long-term care facility)

phone report immediately

written report w/in 2 business days

internet report immediately addresses both requirements if done immediately

Timeframe for reporting elder/dependent adult abuse (if in long-term care facility, NOT state hospital/developmental center, no serious injury, caused by a resident with dementia )

report w/in 24hrs to local ombudsman & law enforcement

Timeframe for reporting elder/dependent adult abuse (if in long-term care facility, NOT state hospital/developmental center)

report immediately to law enforcement

written report within 24hrs to local ombudsman and state licensing agency

Timeframe for reporting elder/dependent adult abuse (if in state hospital/developmental center, resulted in death, sexual assault serious bodily injury)

immediately to state dept of developmental services

AND

local law enforcement

Timeframe for reporting elder/dependent adult abuse (if in state hospital/developmental center, did NOT result in death, sexual assault serious bodily injury)

immediately to state dept of developmental services

OR

local law enforcement

Does child abuse reporting require CA residency?

No; you must report regardless of where they live

reasonable suspicion

other reasonable practitioners would report with the same information -- invitation to consult

For a child abuse report, is direct knowledge necessary?

no, do not have to hear directly from the victim

Physical abuse definition

intentional striking of a child that leaves an injury (exceptions for law enforcement and school officials)

sexual abuse - child pornography

downloading/streaming with INTENT or distributing any images of minors

even two minors sending each other photos

When must you report heterosexual intercourse if there is consent?

Two rules:

- 14th birthday rule (if one is under and one 14 or older, it's a report)

- 16/21 rule (if one partner is old enough to drink, the other must be old enough to drive)

When are other forms of consensual sexual activity (oral sex, anal sex, object penetration) with a minor reportable?

Look ONLY at the 16/21 rule

lewd and lacivious act

non-penetrative sexual contact i.e. mutual masturbation

When must you report lewd and lascivious acts?

- If one partner is under 14yo, always a report

- if one partner is 14 or 15 and other partner is 10 or more years older

- 16 or older, not a mandated report (regardless of the other's age)

If a 16 year old consensually engages in lewd and lascivious acts with someone older than them, is it a mandated report?

No

If a 13 year old consensually engages in lewd and lascivious acts with someone, is it a mandated report?

Yes, always if under 14

When must you report a 14 or 15 year old consensually engaging in lewd and lascivious acts?

If the partner is 10 or more years older

When must you report non-consensual sex between two minors?

Always

"Informed and appropriate" medical choices made by parents

- decisions due to religious or spiritual beliefs to decline medical care for child is not reportable

- child must at least be examined by a physician

- appropriate = refusal is not life-threatening

Does child neglect have to have caused harm to be reportable?

No

Child Abuse/Negect in Out-of-Home care

schools, day cares, other care settings

- CPS may get other agencies involved (law enforcement, licensing boards)

Is emotional abuse a mandated reports under the law?

No, it is "permissive" rather than mandatory

When is emotional abuse commonly reported?

When children witness domestic violence.

Permissive report, not mandatory

Timeframe for child abuse reporting

- report immediately by phone

- 36hrs for written report (clock doesn't stop for weekends/holidays)

- internet reporting counts for both if made immediately

- good faith protection from civil/criminal legal action

Are you legally required to break confidentiality if there is a threatened suicide?

Not if you believe you can effectively intervene through other means

use least intrusive, effective means possible

Are you mandated to report an individual who is likely to spread a dangerous infectious disease?

Not required by law, but you are allowed to break confidentiality to contact public health officials

If a client as an imminent threat to the danger of others but there is no specific victim (i.e. danger to someone on the street)

move toward involuntary hospitalization, cannot warn intended victim

requires that the person be a danger to others because of a physical or mental disorder

When is it not appropriate to ward intended victims of an imminent threat of severe bodily harm?

If it would cause more harm (i.e. mutual IPV, gang violence, etc.)

If you resolve a tarassof threat (i.e. person is de-escalated before enacting harm), what must you still do?

Notify law enforcement within 24 hours

puts them on federal database that prevents them from purchasing firearms

Duty to protect

Most often in tarassof, you would contact law enforcement immediately and notify intended victim (unless it would heighten danger for those involved)

no obligation to warn, but you have additional protection from legal liability when you attempt to do so

Ewing v Goldstein

allows clinicians to consider 3rd party information when determining risk level

Risk to property

cannot break confidentiality if there is threat exclusively to property.

But if it could also cause severe bodily harm, tarassof is at play

Grave disability

can be involuntarily hospitalized if, because if a mental illness or severe substance use disorder, they are unable to meet basic needs for food, clothing, shelter, personal safety or necessary medical care

What did the law in 2024 expand grave disability to include?

both mental health disorder and severe substance use disorder

Are poverty, homelessness, or poor health (in and of themselves) indicators of grave disability?

Not necessarily. Shouldn't involuntarily hospitalize if what they need is to be connected with resources/services.

Must be because they are not able to meet survival needs

If a client needs to be hospitalized, is involuntary or voluntary hospitalization preferred?

voluntary

How long can I client be held Is placed on 5150 hold

up to 72 hrs, can be less

If somebody is still a danger to self after initial 72hrs on 5150 hold

can be held up to 14 additional days, even more if client needs to be put on conservatorship

Rights of clients involuntarily hospitalized

anyone held beyond initial 72hr limit has right to lawyer, interpreter, and court hearing