Case Study
Patient Demographic: Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0)
Mental Status Exam: Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso
Presenting Problem: You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being.
Other Contexts: The client reports that he has been sleeping more than usual and that this is affecting his ability to get to work on time. He reports that his boss started noticing his tardiness and has given him a verbal warning. Combined with the fear of losing his job, he expressed worry regarding increased conflict with his girlfriend and feeling more “on edge.”  The client asks the clinician to call his girlfriend for some more insight into how depression is affecting his functioning

Question: The client asks the clinician to call his girlfriend for some more insight into how depression is affecting his functioning. What is important to obtain in order to facilitate this collaboration?
(A): A signed informed consent form
(B): A signed release of protected health information (PHI)
(C): A written and signed letter of consent from the client
(D): Verbal consent from the client to collaborate with his girlfriend

Correct Answer: A signed release of protected health information (PHI)
Explanation: The Healthcare Information Portability and Accountability Act of 1986 (HIPAA) Privacy Rule requires a signed release of PHI before a client’s health information is shared with individuals internal and external to a facility (except for people directly involved in the client’s care). The signed release of PHI identifies to whom the information can be provided, what information can be provided, what method of communication is permitted, and how long the communication can continue. Informed consent, although required in many circumstances, does not provide permission to release information and is more relevant to obtain from clients prior to performing procedures or interventions after the details, risks, and benefits have been thoroughly discussed. A written or verbal consent from the client would not be sufficient for this kind of contact. Therefore, the correct answer is (C)
Competency: professional practice and ethics