EHR and practice management for mental / behavioral health
PIMSY mental health EHR guest blog: when a client wants SSI or SSDI

When a Client Wants SSI or SSDI

by Beth Rontal, LICSW, 7.23.16

A therapist recently asked me how to handle a request from the Social Security Administration for the medical records of a client she hadn’t seen in several months and only for two sessions. The request was accompanied by a signed release, so the client was approving the release of the records, but the therapist did not have them.

Is The Therapist Qualified? 

Not having access to the client’s medical record could be problematic. But the real issue at this moment is whether the therapist is truly qualified to comment on this client’s ability or inability to work having seen her only two times and not recently.

When my supervisees face this situation, I tell them that the client needs to be seen at least six times before an assessment can be made so that professional integrity is maintained. This stand can sound harsh to people who need aid and have no other place to turn. But I’m not refusing to write the letter or complete the form; I’m refusing to write it based on no useful information.

Take Away 

The SSI and SSDI forms are extensive, requiring specific answers about tasks of daily living that – in my experience – are not discussed in the first two sessions. It can take me up to two sessions just to complete the government form properly, let alone do an Intake Session, where the focus is signing releases, reviewing HIPAA and taking a history of the presenting problem. 

The good news is that a structured discussion about the client’s level of ability to perform tasks of daily living can provide a lot of good information for the therapeutic process itself and deserves the time it takes to get the information. 

Ask the Expert

We’re giving you an exclusive opportunity to ask Beth your documenting questions. Email your inquiry to – and we might feature the answer in an upcoming blog post!

click here for pdf 

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Beth Rontal, MSW, LICSW, has spent thousands of hours teaching psychotherapists how to document medical necessity, get authorizations and pass audits by linking effective documentation with good clinical practice.  

An engaging speaker, Beth has presented Misery or Mastery; Documenting Medical Necessity to individuals, groups and clinics and at national conferences. She also serves on the Advisory Board of PIMSY Mental Health EHR. For more information, see Documentation Wizard

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