Case Study
Patient Demographic: Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0)
Mental Status Exam: Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f
Presenting Problem: You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it.
Other Contexts: rail. Family History: The client got divorced about 1 year ago. He states that his wife left him because he lost his job and because of his fentanyl use. The client has two children that are 18 and 22 years old. The client no longer has contact with his ex-wife or children. The client reports no known mental health history or substance use history in his family.  The client signs a release of protected health information (PHI) for his primary care physician (PCP)

Question: The client signs a release of protected health information (PHI) for his primary care physician (PCP). Which of the following would be the most ethical level of disclosure of PHI to provide to the PCP?
(A): Provide minimal information regarding the client’s mental health’s effects on his physical health.
(B): Provide the client’s progress notes and treatment plan.
(C): Provide a biopsychosocial assessment so that the PCP has a well-rounded view of the client.
(D): Provide information on treatment participation and progress.

Correct Answer: Provide minimal information regarding the client’s mental health’s effects on his physical health.
Explanation: According to the ACA Code of Ethics,minimal provision of information is an important ethical consideration because you only want to disclose what is absolutely necessary (ACA, 2014). The PCP would only need to know what pertains to their specialty and their service provision, which would be the client’s mental health and its impact on his physical health. Provision of progress notes, biopsychosocial assessment, treatment plan, and client treatment participation could be providing more than is necessary for coordination between services, exceeding the counselor’s ethical obligations. If the provider were a psychiatrist prescribing mental health medication, the other areas would be more relevant for them to know. Therefore, the correct answer is (A)
Competency: professional practice and ethics