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Document clinical assessment and treatment of mental health issues. These records found in all media (paper, digital, or other) may include but are not limited to:

• identifying data; contact information; fees and billing information;
• where appropriate, guardianship or conservatorship status;
• documentation of informed consent or assent for treatment;
• documentation of waivers of confidentiality and authorization or consent for release of information;
• documentation of any mandated disclosure of confidential information (e.g., report of child abuse, release secondary to a court order); presenting complaint, diagnosis, or basis for request for services;
• plan for services,
• updated as appropriate (e.g., treatment plan, supervision plan, intervention schedule, community interventions, consultation contracts); health and developmental history;
• related documentation.