The Clinical File
The clinical file contains the documentation of a client’s assessment and treatment plan. It is a useful organizational tool and a helpful and rich source of valuable information.

The Client’s Assessment
The assessment describes the identified problem, and includes the client’s relevant history, strengths, goals, and needs or concerns regarding therapy. Services that have been, or will be, provided are recorded here as well. A clinical formulation and a plan for treatment or service plan can also be found in the clinical file.

The Client’s Treatment or Service Plan
The treatment or service plan includes a statement of the client’s needs and strengths, and takes into consideration his or her views, and those of the family. It outlines the methods, goals, and expected length and outcomes of treatment. It records the client’s progress, and sets forth agreed upon plans for termination, including follow up services that may be necessary or desired.

The plan is developed by the client, the worker, and other involved professionals. The client’s family may also be included in the process.

Clinical Record Keeping
EMYS is committed to protecting every client’s privacy as per legislative requirements, and in accordance with Children’s Mental Health Ontario accreditation standards. Only information essential to treatment is collected. Clients have access to their files at any point during and after their time in treatment. Upon request, a copy of any EMYS report will be made available to the client.