Practice Matters is an occasional posting about timely, clinical topics of interest to psychotherapy service. Topics are generated by the Practice Advisory service, provides information for registrants on various topics that emerge as key trends. Got a question or an idea for us to cover? Email qa@crpo.ca with your thoughts.

Q: Can I display my PhD or other credentials on my business card and website?

It’s important that registrants not mislead the public about their psychotherapy credentials, which is why the practice standard about use of titles exists. This standard indicates that “the credential to be displayed must be one that is related to the practice of the profession.” This means that, if your degree or credential is not directly related to the practice of the psychotherapy, it should not appear alongside your other credentials or appear prominently on your website.

If you are not sure if your credential is related to the practice of the profession, ask yourself whether the program’s curriculum or your research addressed established psychotherapeutic theories and/or theories of human development, and whether it was concerned with the development of the skills that are necessary to engage a client in a safe, effective therapeutic process. If the answer to both questions is yes, then the credential is likely to be one that is related to the practice of the profession. If the answer to both is no, then it’s very possible the credential would not be considered related to the practice of the profession, in which case, you would be running afoul of CRPO standards.

From the standard on use of titles:

Use of the title “Doctor” or “Dr.” is protected in the RHPA. Members of this College are not permitted to use this title in a clinical setting. If a person is not from one of the health professions entitled to use the doctor title (chiropractic, optometry, medicine, psychology, dentistry) or a social worker with an earned doctorate degree in social work, s/he cannot use the title “Doctor” or “Dr.” in a clinical setting. This is the case even if the person has an earned doctoral degree (e.g. the person holds a Ph.D). Under this provision, the title “Doctor” can be used in other settings, socially or in a purely academic setting, where no clients are present.

Note: The above does not prevent a member from displaying a Ph.D or other doctoral degree in his/her promotional material, if the degree is their highest credential earned and is related to the practice of the profession.

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Q: What happens to my clients and clinical records if I’m suddenly no longer able to practise?

Planning for the unexpected will help you and your clients should you ever find yourself in a position where you are unable to practise. Indeed, Professional Practice Standard 6.4: Closing, Selling, or Relocating a Practice requires that CRPO registrants have a contingency plan in place that will:

  • ensure the standards of the profession are met, even if you are not providing the services yourself;
  • link your clients with other qualified professionals who can address their needs; and
  • assure that your clients and/or their new providers have timely access to relevant information about the client’s care.

While the particular details of a contingency plan will depend on your practice, it is likely to include:

  • the contact information for one or more individuals (designates) who have agreed to carry out specific tasks on your behalf in the event you are suddenly unable to practise;
  • a list of contacts, including clients and colleagues and others with whom you have significant professional relationships;
  • directions for the designate(s), including those that relate to contacting clients or their substitute decision-makers to inform them of the situation, provide referral information, and discuss maintenance or transfer of clinical records.

Below are some considerations that will help as you shape your contingency plan. Your own research and discussion with colleagues will also be helpful in your planning process.

Identifying an appropriate designate

In the event you were unexpectedly unable to practise, how would your clients learn that you are no longer available to provide services?

  • If you are self-employed in a private practice, you will need to identify an appropriate designate who can carry out specific aspects of your contingency plan.
  • If you work in an agency or hospital setting, it’s possible that a contingency plan already exists to address such a situation – you might find it helpful to speak with your manager for more information.
  • If you provide services under contract to a third party, it will be helpful to carefully consider any existing contracts, policies set by the third party, and your overall role in order to understand what responsibilities would fall to a designate.

When selecting a designate, ensure they have the competence necessary to fulfill the duties set out in the contingency plan. Standard 6.4 does not indicate that a designate must be a fellow RP; however, it would be helpful for the designate to at least be a member of a regulated health profession in Ontario, as these individuals are likely to be familiar with the framework of health care law and regulation.

Understanding the needs of the clients you serve is also important, as this is likely to influence your selection of the designate who will carry out specific duties described in the plan, in addition to your plans for referral of clients to other suitably qualified professionals.

Referral to Alternate Service Providers

Professional Practice Standard 1.9: Referral identifies that registrants must refer their clients to other qualified, competent professionals when they are not available to provide services. In light of this, your contingency plan must take into account referral to other professionals where applicable, as would be the case if you had active clinical files. The reasons for the referral must be explained to the client, and, if the referral process requires disclosure of the client’s personal health information, the client’s consent must be obtained before their information is disclosed.

See Standard 1.9 for more information.

Clinical Records

According to the Personal Health Information Protection Act, individuals who have received health care services in Ontario have a right to access to the personal health information that is contained in clinical records. Health information custodians are responsible for ensuring that clients have access their personal health information in a timely manner.

Health information custodians are individuals or organizations who have custody or control over a client’s personal health information. For example, an RP in private practice is responsible for storing and maintaining client clinical records, and would likely be considered the health information custodian; an RP who is an employee at a hospital or agency, on the other hand, is likely to be considered an agent working on behalf of a health information custodian, i.e. the hospital or agency.

Professional Practice Standard 5.1: Clinical Records identifies that CRPO registrants must maintain clinical records “for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later.”

If you are the health information custodian, your contingency plan must:

  • account for the maintenance of clinical records in a manner that accords with relevant laws and the Professional Practice Standards; and
  • include measures that will facilitate client access to their personal health information, or transfer of the client’s personal health information to another health provider, for the period defined in the Professional Practice Standards.

See Standards 5.1 and 5.6 on record-keeping for more information.

Instruction to Designate to Notify CRPO

As you prepare your contingency plan, consider adding an instruction for your designate to contact CRPO in the event of your death or incapacity to provide the following information:

  • relevant information about the circumstances; and
  • the name and contact information of the health information custodian designated in the contingency plan.

This information would be retained in CRPO’s records and used only to facilitate a client’s access to their clinical records. Only the name and contact information of the designated health information custodian would be shared.

By including this instruction in your contingency plan, you would be increasing the likelihood that a client would be able to access their clinical records in the event you are not available to provide access yourself.

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Q: I’m working with a young child whose parents are going through a divorce. What do I need to know about consent in this situation?

According to Professional Practice Standards Section 3: Client-Therapist Relationship, registrants have a duty to place the well-being of the client at the forefront of the therapeutic relationship. With this in mind, consider the following:

The client’s ability to provide consent

In Ontario, there is no “age of consent” with respect to personal health care decisions. In general, clients of any age are considered capable of refusing or providing consent to their own treatment as long as they possess the maturity to reasonably understand the information provided and can appreciate the consequences of their decisions. Where a client is a minor (e.g. under the age of 16 for health care decisions, or under the age of 18 for decisions involving contracts), their capacity to provide consent must be determined on a case-by-case basis.

Every health practitioner who proposes a treatment to a client may perform this type of capacity assessment. Registrants are advised to use their professional judgement and to exercise appropriate care in determining whether a child is capable of consenting to treatment. Where a registrant determines that a child is incapable, treatment may not be carried out unless consent has been obtained from an appropriate substitute decision maker (SDM). Review Standard 3.2: Consent, to see the hierarchy of SDMs.

Keep in mind that a client may be capable of giving consent for some aspects of care, but not others. It is registrants’ responsibility to identify the points where consent is possible and to engage the client in an appropriate informed consent process.

Custody orders and parental agreements

Where a client is not capable of providing consent, it is important to know information about the custody arrangements and whether a custody order or parental agreement exists, as these will inform who may make health care decisions on behalf of the child. For example, even when parents have joint custody, there may only be one parent who, under the custody order, may make decisions relating to the health care of the child.

This document provides information about the differences in custodial arrangements and the implications for health care decisions. See the section entitled “Caring for your children” where these concepts are explained:

Sharing personal health information

In situations where the client is a minor who is capable of providing consent, be advised that you will require the client’s informed consent in order to share their personal health information with parent(s) or guardian(s). Sensitivity to the issues that can arise in cases of separation and divorce, along with an awareness of the client’s particular concerns, will help you provide the information the client needs to make informed decisions about the sharing of their personal health information.

For more information, see our Informed Consent Workbook.
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Q: I’m registered with CRPO and another college. As a dually-registered practitioner, what do I need to know?

Practice Standards
As a starting point, dually-registered professionals are encouraged to review the standards and policies of the colleges with which they are registered. Many colleges have specific standards that apply to dually-registered professionals, though CRPO does not have such resources at this time. Until a standard or guideline on this subject exists, CRPO registrants are encouraged to carefully review CRPO’s Professional Practice Standards in light of their dual practice, in particular Standards 1.2: Use of Terms, Titles and Designations, 1.6: Conflict-of-Interest, 1.7: Dual or Multiple Relationships, 3.1: Confidentiality, 3.2: Consent, 5.3: Issuing Accurate Documents and 6.2: Advertising and Representing Yourself and Your Services.

Administrative Matters
There are a number of administrative matters that a dually registered professional should be aware of. An obvious example is the annual registration process – the dually-registered practitioner is required to complete the annual registration requirements, including any forms and payment of fees, of each college they are registered with. In addition, the dually-registered practitioner is required to engage in the quality assurance programs of any colleges they are registered with; this includes meeting the QA requirements and deadlines of each college.

Complaints
Dually registered professionals should be aware of the possibility that a concern or complaint against them can be received by one or both colleges. While each college independently investigates complaints filed against its registrants, it is possible that in some cases a complaint filed against a registrant with one college could prompt an investigation by the other college, even if the complaint was not originally filed with that college.

Considerations
Being dually registered also has implications for clinical practice – a few examples will be covered off here. For more information, registrants are encouraged to connect with CRPO’s Practice Advisory Service.

The nature of your dual-practice – Depending on the nature of your dual practice, there may be some overlap in the work you do as an RP and the work you do in your other professional capacity. Dually-registered professionals are encouraged to think carefully about where any overlap may or may not occur in their practice. If your other profession does not overlap with psychotherapy, consider whether it is appropriate to refer or treat the same client in the other role.

Providing information for informed consent – Clients are entitled to provide informed consent prior to any treatment. In order for a client’s consent to be considered informed, they must be provided with all the information that one would need in order to make such a decision. Because of potential confusion, it is important that dually-registered practitioners describe their practice and services as accurately as possible, taking care to clarify to the client when the dually-registered practitioner is working in their capacity as a psychotherapist, or when they are working in their other professional capacity.

Maintaining clinical records – The dually-registered practitioner should be mindful that they will be expected to maintain clinical records in a manner that meets the standards of each college with which they are registered.

Billing – CRPO registrants are required to issue clear, accurate documents to third-parties. This means that receipts and invoices should include an accurate description of the services provided to the client, and it should be clear in all financial records in which professional capacity the rgistrant was working in when those services were provided to the client.

This FAQ does not address registrants who practise in unregulated fields in addition to the regulated profession of psychotherapy. This will be addressed in a future article.
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Question: Are CRPO registrants required to charge HST?

Whether or not a registrant is required to charge HST is largely determined by the Excise Tax Act, which is federal law. It includes a list of exemptions that exempt services that are provided by specific professionals. RPs do not appear on the list of professionals whose services are exempt from HST. There may be some situations in which an RPs services can be exempt from HST; however, your accountant or a Canada Revenue Agency representative would be in the best position to provide guidance that is specific to your situation. See Schedule V, Part 11 of the Excise Tax Act.

Are the services provided by a CRPO registrant eligible for a tax credit?

A Government of Canada website identifies that Registered Psychotherapists appear on the list of “Authorized medical practitioners for the purposes of the medical expense tax credit.” We also understand that “therapy plan” and “therapy” appear on the “List of common medical expenses” that are eligible for a tax credit. These services are only eligible for the tax credit when specific conditions are met – please visit the Government of Canada’s website or contact your tax advisor or accountant to explore how this information could impact your practice.​

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Question: I am an RP and I am opening a private practice. I’m confused about fees and billing. How much should I be charging my clients? What should my receipts look like? What needs to be included? What are CRPO’s guidelines? I want to make sure I am doing this correctly for CRPO and also for my clients.

Setting Fees
According to Professional Practice & Jurisprudence for Registered Psychotherapists, “Establishing professional fees charged by members is not within the mandate of the College, and the College does not set the fees for members’ services. In fact, the college does not regulate the amount a member may charge a client, unless the fee is excessive. A fee is considered excessive if it takes advantage of a vulnerable client or is so high that the profession would conclude that the RP is exploiting a client.” For additional information regarding fees, consult the Professional Practice Standards, Standard 6.1: Fees.

Billing and Receipts
Many registrants, especially those in private practice, collect payment after each psychotherapy session and issue a receipt to the client. The College has information on financial record-keeping, including billing and receipts, in the Professional Practice Standards, Standard 5.3: Issuing Accurate Documents and Standard 5.5: Record-keeping – Financial Records. Members must provide clients with accurate records and other documents, including invoices, bills and receipts.

In short, receipts should include:

  • the registrant’s legal name (and any alternate name used in practice);
  • title conferred by the College and registration number;
  • amount paid;
  • date the service was provided;
  • type of services provided; and
  • full name of the client.

Members are expected to be accurate, transparent and reasonable in their fee and billing practices. For example, if a member works with associates, it should be clear which psychotherapist saw the client.

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Question: I practise in Ontario but have a client outside of Ontario who wants to work with me. 

Whether a client resides in Ontario or in another jurisdiction, registrants may provide services using communications technologies as long as:

  • they are able to do so competently and in a manner that abides by the Professional Practice Standards;
  • there is no law, regulation or standard in the other jurisdiction that would restrict or prohibit the registrant from providing services to a client located in that jurisdiction; and
  • they have appropriate liability insurance coverage considering the particular technologies used to provide services, the risks these technologies may present, and the possibility that the registrant’s practice will cross into other jurisdictions.

Registrants who provide psychotherapy using communications technologies (e.g. phone, video conference, etc.) have an electronic practice. Professional Practice Standard 3.4: Electronic Practice and the accompanying Guideline set out expectations for registrants who engage in electronic practice, some of which are highlighted below.

Registrants who wish to work with a client located in another jurisdiction must determine whether any law or regulation in that jurisdiction that would prevent them from providing therapy to the client. This might require, for example, that registrants investigate whether the practice of psychotherapy or counselling is regulated in the client’s jurisdiction and if so, that the registrant makes inquiries with the regulatory body there.

To an extent, a communications platform is its own therapeutic milieu that influences the therapeutic relationship and the therapy itself. Being able to leverage this therapeutic milieu safely and to the benefit of clients is an important skill. Familiarity and comfort with the technologies that are used in electronic practice can help registrants meet their obligations with respect to confidentiality and enable them to resolve technical issues that might arise during a session.

Before any therapy is provided, registrants must first evaluate the appropriateness of therapy, given the nature of the client’s concerns, their ability to access technologies safely and privately, and their overall comfort and capability with communications technologies. Therapists must also consider whether providing therapy in this manner would present a risk of harm to a client in light of the client’s symptoms and individual risk factors, for example safety in the home or possibility of adverse reaction during therapy.

There are added considerations for the informed consent process. For example, registrants are expected to enter into a contract with clients before providing services. In addition, therapists must inform clients of the technologies that will be used and discuss the risks to confidentiality that these technologies may present.

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Question: I am not in Ontario but I have a client in Ontario who wants to work with me. 

Therapists working outside of Ontario with clients in Ontario must use the same principles as those RPs who are within Ontario and are working with clients outside the province (i.e. see the question and answer above). In other words, they must be able to do so competently, there must be no law or standard in the jurisdiction where the therapist is that would restrict them from providing care outside that jurisdiction, and they have appropriate liability insurance.

CRPO does not require practitioners who reside in another jurisdiction to become registered in order to work with a client in Ontario providing:

  • the therapist does not intend to advertise or otherwise promote their services in Ontario; and
  • Ontario-based clients do not form a substantial proportion of the therapist’s workload

If any of these factors were to change, CRPO would revisit the facts and consider whether the therapist should apply for registration, even on a temporary basis.

Therapists who do not reside in Ontario, but who provide services to Ontario-based clients remain responsible for their conduct even if they are not registered with CRPO, and given our mandate for public protection, CRPO may be required to take action if a situation arose that was a matter of public protection, for example, by requiring that an individual cease practising psychotherapy in Ontario.

When we speak to our own registrants about providing distance therapy, we explain that they must engage the client in a thorough informed consent process in order to assure the client is aware of the risks and benefits of distance therapy, and to assure that the client is aware of alternate options. Our registrants must be aware of local laws, requirements and standards of practice. In consideration of the client’s particular risk factors, our members must also develop appropriate safety plans, which may include linkages to local supports. And of course, our registrants are encouraged to refer appropriately when the need or occasion arises. You can review our Standard on Electronic Practice for more information.

Other resources:

Selecting a Communications Platform for Electronic Practice
Electronic Security Practices Self-Assessment
Switching to Electronic Practice During COVID-19

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Question: Is it preferable to keep paper or electronic files?

Registrants (or the organization they work for) are free to choose whichever record-keeping system is best suited to their needs and access to technology. The same principles apply to both paper and electronic record-keeping. For example, modifications to any record need to be tracked. In other words, the originals must not be overridden or erased.

Security of paper records would include locking and storage, while for electronic records it would include encryption, virus prevention, backups, and physically restricting access to the computer and display. When using electronic record-keeping systems, an alternate process for record-keeping must be ready in case the electronic system is down or unavailable. Check out CRPO’s Professional Practice Standard 5.6: Recordkeeping – Storage, Security and Retrieval as well as the CRPO Professional Practice and Jurisprudence Manual for more detail.

Question:

I have been using paper in the past and want to switch to electronic record-keeping. Can I scan and destroy the paper copies?

Answer:

There are options when it comes to transitioning from paper to electronic record-keeping. You may either convert all existing paper records into electronic form, or retain paper records and begin entering information into an electronic format on a subsequent basis. In either case, client care and appropriate record-keeping practices must continue without interruption.

When scanning paper records, registrants are responsible for ensuring their integrity upon conversion into electronic format. This includes verifying that documents have been properly scanned and that the entire record is intact, including any attached documents and notes. You should establish specific procedures for converting files and document these procedures in writing. It may be helpful to enlist a reputable commercial organization to assist in this process[1].

The Information and Privacy Commissioner of Ontario states that old paper records should not be destroyed unless the required retention period has expired or the entire paper-based record has been duplicated in electronic format[2].

Question:

How do I determine who is the “health information custodian”?

Answer:

CRPO often receives questions about who is responsible for health information recorded by a registrant. The answer to this question depends on identifying the “health information custodian.” The term “health information custodian” is defined in the Personal Health Information Protection Act, 2004 (PHIPA) [3,4]. In short, a custodian is an individual or organization that has has custody or control of personal health information.

If practising alone, a registrant is the health information custodian of their clients’ information. If employed by another health information custodian such as a hospital, the employer is the health information custodian and the registrant is expected to follow the record management practices of their employer.

Where a registrant is employed by a non-health organization such a school, university, college or municipality, the registrant is considered to be the custodian. In these situations, the registrant cannot disclose personal health information to his or her employer without the client’s consent or another legal exception.

In other situations, the answer may not be clear, and registrants will need to speak with their employer. The Information and Privacy Commissioner of Ontario also has resources on this topic [5,6].

Question:

How do I properly destroy my client files?

Answer:

Records need to be kept for 10 years from the last interaction with the client or from the client’s 18th birthday, whichever is later. Financial records, appointment and attendance records need only be kept for five years [7].

When the time period for keeping the record has expired, the records should be destroyed. If the therapist destroys any records, they should record the names of the destroyed files and the date they were destroyed.” For paper records, destruction means cross-cut shredding, not simply continuous (single strip) shredding, which can be reconstructed. You should consider pulverization or incineration of records that are highly sensitive. You might also hire a licensed service provider to destroy your files. In doing so, look for a provider accredited by an industrial trade association, such as the National Association for Information Destruction (NAID) [8].

For questions about confidentiality and health records, contact the Information and Privacy Commissioner of Ontario.
https://www.ipc.on.ca
Toronto Area: 416-326-3333
Toll Free: 1-800-387-0073
info@ipc.on.ca

[1] From “Ontario Policy Statement # 4-12, Electronic Records”, 2000, College of Physicians and Surgeons, p. 5.
[2]From “Personal Health Information: A Practical Tool for Physicians Transitioning from Paper-Based Records to Electronic Health Records”, 2009, Information and Privacy Commissioner of Ontario, p. 20.
[3]From “Frequently Asked Questions Personal Health Information Protection Act”, 2015, Information and Privacy Commissioner of Ontario, p.7-9.
[4]From “Personal Health Information Protection Act”, 2004, Information and Privacy Commissioner of Ontario, Section 3(1).
[5] From “A Guide to the Personal Health Information Protection Act”, 2004, Information and Privacy Commissioner of Ontario.
[6]From “ Frequently Asked Questions Personal Health Information Protection Act”, Information and Privacy Commissioner of Ontario, 2015.
[7]From “Professional Practice Standards for Registered Psychotherapists”, 2014, The College of Registered Psychotherapists of Ontario, page 68.
[8]From “Personal Health Information: A Practical Tool for Physicians Transitioning from Paper-Based Records to Electronic Health Records”, 2009, Information and Privacy Commissioner of Ontario, p. 22.

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Question: I am an RP. I work for an agency and also have a private practice. What are CRPO’s guidelines for referring a client of the agency to my private practice?

CRPO’s Professional Practice Standard 1.9: Referral, states that a member may “self-refer” a client from one practice to another, in certain circumstances. The key is allowing the client to make an informed choice and not taking advantage of an existing professional relationship in order to secure more business. This Standard also provides a description of what a self-referral is, when a self-referral may be made, safeguards to avoid a conflict of interest as well as exceptions.

Some employers may not allow registrants to self-refer clients to their private practice. In this case, registrants should act in accordance with their employer’s policies; the College generally does not get involved in employer-employee issues.

Please consult Standard 1:9: Referral, for additional detail.

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Question: My employer’s policies clash with CRPO’s practice standards. Which one should I follow?

CRPO registrant (not her real name) called our practice advisory service because she was feeling concerned that the policies at her place of employment clashed with CRPO’s professional practice standards. She explained that she provides psychotherapy to people using their employee assistance plans. The problem is that her employer does not want Jane to disclose to clients that they are only entitled to have four to five appointments with her. Jane was aware that this limitation may not support the well-being of her clients, which is at the heart of standards of practice. She felt worried that her employer’s policy was impeding her ability to meet CRPO’s standards.

Our practice advisor asked Jane if she had spoken with her employer about how this policy would be applied in situations where longer-term therapy would benefit the client. She replied that, yes, she had raised concerns about the potential for a negative impact this would have on clients, but the employer had not been moved to change the policy.

She noted that she was considering raising the matter as an informed consent issue. Jane had used the CRPO Informed Consent Workbook, and was aware that laws, such as the Health Care Consent Act (HCCA) and the Personal Health Information Protection Act (PHIPA), set the basic requirements of the informed consent process. Jane knew she was responsible for ensuring that her clients had given informed consent before any assessments or treatments are provided, and before collecting, using and disclosing the client’s personal health information. While her place of employment had an informed consent policy and process in place, it had a gap when it came to information about restrictions on the number of appointments.

The limitations to the services that Jane is able to provide to a client should be disclosed as part of informed consent. Transparency about limitations to services may help the client and their therapeutic process, particularly when establishing therapeutic goals and treatment plans that are realistic and when considering the client’s longer-term needs for self-management and/or further services.

Our practice advisors suggested that Jane had a couple of options: one was to approach the employer again and advocate on behalf of her clients’ well-being, as well as her own interests as a regulated health professional who is required to meet certain standards.

Her other option was to seriously consider whether she wanted to continue in an employment relationship that was impeding her ability to support safe practice and client well-being.

The practice advisory reminded Jane that if she needed to discontinue services in order to comply with an employer’s policy, she must do so in accordance with the Professional Practice Standards 6.3: Discontinuing Services.

Jane decided that the informed consent angle was how she would approach the matter. She decided to approach her employer and make the case that providing additional information to clients was important, as was  to checking in with clients to see whether that additional information impacted their decision to proceed with (or refuse) treatment. This felt like the safest and most ethical approach, in light of the circumstances. Jane realized that she would not be able to compel her employer to allow more therapy sessions, but she felt that the changes to support appropriate informed consent would be a reasonable compromise, that only needed a minor policy change within the organization. Jane contacted us again recently to let us know she is actively working with her employer to implement this new policy.

Understandably, these potential conflicts can be frustrating, even distressing, for a practitioner who recognizes when they have an obligation to meet standards of practice even when doing may result in friction with their employer. While CRPO regulates individuals, not employers, we encourage employers to establish policies that align with standards of practice that are relevant to the professions that work within the organization.

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Professionalism in business relationships.

When an RP enters into a private practice business arrangement with another person, it is essential that they address key details of their business relationship at the outset in order to prevent the possibility of confusion and disruption in client care. Along with the commercial aspects of business (remuneration, marketing, etc.), these details should include the informed consent process, information and documentation practices, and what will happen when the business relationship ends.

Registrants considering entering into a business arrangement need to take into consideration the requirements and standards of practice that apply to CRPO registrants and any other regulated health professionals who may be involved. Below is guidance for CRPO registrants to assist them in this regard.

Principle-based decision-making

CRPO registrants can look to the Professional Practice Standards for useful guiding principles that can help assess if the particulars of a business arrangement are ethical and/or aligned with the standards. We’ve put together a case study, which appears at the end of this article, to illustrate how the standards can be used.

Identifying the health information custodian

Identifying how the role of the “health information custodian” (HIC) will be addressed within the practice is essential. Under the Personal Health Information Protection Act, 2004 (PHIPA) HICs have specific obligations with respect to security of and access to client personal health information. A first step here is to understand the array of possibilities with respect to who or which entities can occupy the role of HIC. PHIPA lists the individuals and entities that are eligible to act as a HIC.

There are a number of possible arrangements with respect to the role of HIC in a private practice setting. Examples include:

  • A private practice where all regulated health professionals providing care in the setting are HICs. In this case, each individual would be independently responsible for carrying out the obligations of the HIC, which includes assuring that information practices align with requirements and standards of practice, like secure storage of records and client access to their own records.
  • A private practice with a single owner/operator who designates the practice itself is the HIC. In this case, the practice owner/operator would be responsible for naming a contact person who is responsible for carrying out the obligations of the HIC and ensuring that any individuals operating within the setting are abiding by requirements and standardslike maintaining the clinical records after therapy ends and reporting breaches of confidentiality if they happen within the setting.

Designating how the practice will address the role of the HIC at the outset of the business arrangement serves a number of purposes, some of which are listed below. There is no benefit to avoiding this task, as the obligations of the HIC will apply even when one is not explicitly identified and even when one fails to recognize when they are considered a HIC. Designating a HIC:

  • Enables a more thorough informed consent process with respect to collection, use and disclosure of client personal health information.
  • Clarifies who is responsible for specific information practices within the setting, and to what extent.
  • Determines appropriate courses of action when there are questions or issues that arise with respect to management of the records or handling of a client’s personal health information.

Informed consent to treatment

A client should be made aware of the nature of their relationship with the practice and with their therapist before any assessment or treatment is provided, as this information may be material to a client’s decision to agree to treatment. For example, if the business arrangements within the private practice mean that the client is considered the client of the practice, as opposed to the client of any particular therapist, then the client should be informed of this. They should be made aware of any limitations this may present in, for instance, their ability to transfer between providers within that practice or to continue care with a therapist who leaves that practice. Learn more by reviewing Standard 3.2: Consent.

Consent to collection, use and disclosure of PHI and management of clinical records

Registrants need to obtain informed consent from clients with respect to the collection, use and disclosure of their personal health information. Explaining who has access to the record and for what purposes helps the client understand how their information is ordinarily collected, used or disclosed in the setting. The client should also know who to contact for information about- or access to their clinical records. For example, if an RP in a group private practice is responsible for maintaining their own clinical records, the therapist would likely explain to their client that the therapist themselves is the contact person. In a scenario where the practice itself has taken on the role of the HIC, then the therapist might provide the contact information of a person designated by the practice owner/operator.

Ending business arrangements

Planning for the end of the business arrangement can help to avoid confusion and conflict, it can also promote effective management of care for the departing therapist’s clients.

Standards 6.3: Discontinuing Services and 6.4: Closing, Selling or Relocating a Practice provide fairly specific guidance here. For example, unless there is an appropriate reason to do otherwise, registrants must:

  • Make reasonable efforts to provide advanced notice to clients
  • Provide a reason for discontinuing services
  • Discuss alternate arrangements for services in light of the range of options available, which are likely to include: whether it will be possible to continue with the current therapist in another location, whether the client wishes to continue with a different therapist or alternate service in the current setting or somewhere else
  • Refer the client appropriately

The Standard on discontinuing services indicates that a relationship between a client and their therapist should be able to continue as long as the client is benefitting from the therapy and wishes to continue receiving services. It also provides a number of legitimate reasons for discontinuing services.  With this in mind, a registrant should not agree to business arrangements that place unreasonable restrictions on a client’s ability to receive services from their preferred provider, nor should they actively solicit clients who chose to receive services from another provider.

When a business relationship ends, arrangements may need to be made for the clinical records,  keeping in mind who has been identified as the HIC and ensure the arrangements abide by record-keeping obligations. For example, if each party in the practice is operating independently as a HIC, then the registrant remains responsible for assuring the ongoing management of the clinical records accords with the Professional Practice Standards. If another person is the HIC, then the records would remain with that person. See Standard 5.1: Clinical Records and 5.6: Storage, Security and Retrieval for general information about record-keeping practices. It should be clear to clients where their records will be maintained and who to contact in order to request access.

Case Study

Teri, RP, has a growing private practice. She wants to bring on Mika, RP (Qualifying), who would provide services for some new clients. Teri provides a contract to Mika and asks her to sign it. While reviewing it, Mika noticed a clause that suggested that Mika would not be able to solicit clients of the practice, even after her business relationship with the practice ends. Another clause suggested that if/when Mika’s business arrangement with the practice ended, she would not be able to provide services to clients that she saw in the practice for a period of two years.

Mika called Teri to talk about what would happen with clients if their business arrangement ever ended. Mika explained that when she ended her last internship, there were clients who still needed treatment and who really wanted to continue working with her. Mika was able to work out an arrangement with the internship supervisor so that she could continue working with those few clients for a few more sessions until treatment was concluded.

Teri explained that clients who contact the practice to receive services are considered the clients of the practice, and so if Mika planned to move on from the practice, Mika would need to explain to any clients who wanted to continue receiving treatment that they would be referred to another RP in the practice.

Mika wasn’t comfortable with this arrangement. She turned to the Professional Practice Standards and saw that when it comes to discontinuing services, an RP has to work in a client’s best interests at all times. Also, the relationship should continue as long as the client is benefitting from the therapy and wishes to continue.  Mika asked herself if she would be meeting the standard of practice if she agreed to the terms of the contract as they were currently set out. Mika reasoned that, in a private practice, a client’s options to receive services from their preferred provider should only be limited if there is a good enough reason for doing so. She contacted Teri to discuss the matter again. She resolved that if Teri wasn’t able to offer more flexibility on this matter, she wouldn’t feel comfortable entering into a business arrangement at this time.

I just learned that the police can ask to access my records if they believe it will help in a missing persons case. What should I know about this?

Ordinarily, an RP is required to maintain confidentiality and refrain form sharing their clients’ personal health information. But there are circumstances where an RP is required to share information, or may share information at their discretion. The laws and requirements that govern confidentiality of client health information are mainly set out in the Personal Health Information Protection Act and the Professional Practice Standards, in particular 3.1: Confidentiality.

The Missing Persons Act took effect in 2019, and sets out the processes for sharing client personal health information with police in a missing persons investigation. Health care providers always had the discretion to share information with police if they had reasonable grounds to believe that the sharing would reduce or eliminate a serious risk of bodily harm. In addition, health care providers have always been required to comply with summons, orders or search warrants relating to their records.

What the Missing Persons Act introduces are new pathways. Of greatest relevance: police may request information contained in personal health records under what is referred to as an Urgent Demand, and must use the appropriate form to do so. All or part of the record may be requested, or an oral description of its contents if the police officer consents to it.

While the law allows the clinical record to be provided to police, some have expressed concern about turning over a client’s complete file. If you ever receive an Urgent Demand, we encourage you to review the form carefully. If there is a compelling reason not to share parts of the record that have been requested (e.g. that you are aware the person does not wish to be located), communicate these concerns with the police or contact your legal counsel promptly.

Questions about your practice? Send them to practice@crpo.ca.

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I’m waiting for my application to be approved by CRPO – What can I call myself?

Only CRPO registrants may use the terms “psychotherapist,”[1] “Registered Psychotherapist”, a variation, abbreviation or equivalent in another language.[2] The title Registered Psychotherapist (Qualifying) is also restricted and can only be used by those who have been issued a certificate of registration through the regular application route. Students, individuals fulfilling the requirements to apply to CRPO and people awaiting approval of their submitted application, are not yet CRPO registrants. They may use the titles “student therapist” or “therapist in training.”

While CRPO does not have direct jurisdiction to govern the practices of students and those awaiting approval of their application, CRPO can challenge an application for registration in situations where the applicant has used a restricted tittle or inappropriately represented themselves or their qualifications.

Prospective registrants should also be aware of their obligations with respect to informed consent. It will be important for prospective registrants to take care in how they communicate their qualifications to prospective clients, representing their qualifications and services transparently and accurately in interactions with clients by, for example:

  • Identifying that they intend to become registered with CRPO but are not yet registered. Where an application has been submitted to CRPO by a prospective registrant, clients may find it helpful to know this.
  • Identifying that they are required to practise while under clinical supervision and providing the name of their clinical supervisor.
  • If they are a student, communicating their affiliation with the institution and/or program that is delivering their education and training.

Learn more about how prospective registrants will be expected to represent themselves and their services upon registration by reviewing Professional Practice Standard 6.2: Advertising and Representing Yourself and Your Services. Learn more about consent by reviewing the Informed Consent Workbook.

[1] Registrants of six other colleges may use the title “psychotherapist,” in accordance with the requirements and standards established by their respective colleges and providing they use their regulated title, including the College of Psychologists of Ontario, Ontario College of Social Workers and Social Service Workers, College of Nurses of Ontario, College of Occupational Therapists of Ontario, and College of Physicians and Surgeons of Ontario.

[2] These are restricted titles under section 8(1) the Psychotherapy Act, 2007.

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