Guidance on Documentation
Dear Team,
First of all, I want to acknowledge how it must feel heavy to keep receiving emails with “‼️IMPORTANT…” warnings and difficult updates, and while I don’t enjoy sending them, my commitment is to keep us informed, steady, and moving forward together.
In light of the current political climate, I want to provide clarity and some guidance on two important areas of practice at our clinic:
1. Documentation Practices (Gender Identity & Other Sensitive Topics such as reproductive rights, LGBTQia+, neurodivergence, pro-Palestine, international students, etc.)
Our role is to affirm clients and protect them from potential harm that could arise if their records were accessed outside of our control (e.g., insurance audits, court orders, or governmental intrusion).
Please keep in mind:
Always affirm clients in session, but use neutral or general language in notes unless details are clinically necessary.
Instead of “Client is struggling with gender identity”, use:
“Client is exploring identity development.”
“Client is processing experiences related to self-concept and belonging.”
“Client is navigating stressors related to community or family acceptance.”
**SEE attached PDF for more examples.**
Focus on the function of the work (mood, coping, relationships, resilience) rather than labeling gender identity as a problem.
Document strengths and supports as much as symptoms.
When in doubt, ask: If this record were reviewed by a court, insurer, or other entity, would it affirm the client’s humanity and protect their safety?
Rely on AutoNotes to craft documentation for you by only providing the above suggestions.
**Please see attached PDF for reference**
2. Immigration & ICE Policy at the Clinic
We also want to be clear about our clinic’s stance and procedures if immigration enforcement (ICE) or similar officials were to appear at the office.
Our Policy:
Staff are not to share any client information with ICE or law enforcement without a valid court order signed by a judge.
If ICE or any immigration official shows up at the clinic:
1. Immediately turn on your phone’s camera to document any interaction or instruct your client to do so.
2. Do not engage with them directly about clients or clinicians; if possible lock the door.
3. Immediately notify your Supervisor or any Supervisor.
4. Ask the official to wait outside while leadership reviews any paperwork.
5. Only comply with documentation requests if a warrant signed by a judge is presented and verified. Any other type of documentation is not valid. It MUST be a warrant SIGNED by a judge.
Reassure clients that their confidentiality and safety remain our priority.
**Please see attached PDF for reference**
3. Why This Matters
We are committed to creating a space where every client, regardless of gender identity, immigration status, or background, feels safe, affirmed, and protected. Your careful attention to both how we document and how we respond to external pressures ensures that we remain aligned with our mission of accessible, equitable, and affirming care.
I know these kinds of messages can feel dark, and I don’t take lightly the impact they have on each of us. While I wish I could always be sharing good news, part of my role is to keep us informed and prepared. Please know that we will face these challenges together, with steadiness and creativity, and that I remain committed to supporting all of you and our clients as we move forward.
Thank you all for your diligence, compassion, professionalism, and love for this work in navigating these complexities. Please bring any questions to your supervisor or directly to me. 🙏🏻
Warmly,
Jenn
P.S. The Immigration Policy and Instructions will be posted in each office.
Jennifer Samsom, MA, LPC, LMHC
Executive Director, Clinical Supervisor,
Therapist, Builder of Practitioners (and clinics)
Mindful Therapy Pacific NW, LLC
jenn@mindfultherapypnw.com
www.mindfultherapypnw.com
(503)766-4000