Collateral Contact/Care Coordination Note (Behavioral Health & Therapy Services)

Collateral Contact / Care Coordination Note

Patient Name: [Patient full name]

MRN/DOB: [MRN / DOB]

Date of Contact: [Date]

Time: [Start time – end time or total duration]

Modality: [phone / video / in-person meeting / secure message / case conference]

Author: [Name, credentials, role]

Patient Present: [yes / no]

Contact Summary: [One-sentence summary: with whom coordination occurred, purpose, authorization basis, and key outcome] (Do not duplicate details from sections below.)

Authorization Basis

• ROI Status: [on file / not required / unable to confirm at time of contact] (If unable to confirm, state why and next steps to verify.)
• Scope: [Information authorized to share/receive for this contact] (Document explicitly; do not infer.)
• Basis if no ROI required: [treatment coordination between providers / patient agreed or did not object / professional judgment for incapacitated patient / serious imminent threat exception] (Include only if applicable.)
• Part 2 (SUD) applicability: [not applicable / applicable: SUD information involved, consent status, redisclosure limitations communicated] (If applicable, confirm redisclosure prohibition was communicated.)
• Minimum necessary: [Confirmation that disclosures were limited to information necessary for the stated purpose]

(Do not infer existence of ROI, scope, participants, or disclosures. If information cannot be verified, write "unable to confirm" with explanation and next steps.)

Contact Identification

• Collateral party: [Name; credentials if clinician; relationship to patient; organization/agency]
• Identity verification: [callback to main line / known provider / patient-provided contact / secure portal]
• Other participants: [Names and roles; include interpreter if used]

Unsuccessful Contact Attempts: (Include only if applicable.)

• [Date/time] – [method]; [voicemail left: yes / no]; [minimal content disclosed]; [plan for re-attempt]

Reason for Contact

[Who initiated and why; clinical rationale linking to treatment goals or risk management; specific objectives for this communication]

Communication Content

Information Obtained

• [Source attribution and content, e.g., "Per mother, patient has not slept in three days"; include time anchors and reliability qualifiers as appropriate] (Use direct quotes only for clinically critical statements such as safety disclosures or refusals.)

(Omit this subsection if no new information was received.)

Information Shared

• [PHI or clinical information disclosed and rationale tied to coordination goal]
• (If no PHI disclosed, state explicitly: "No PHI disclosed; provided general information only.")

Safety-Critical Content

• Nature of concern: [Risk concern discussed or identified; level and rationale]
• Actions taken: [Safety planning, crisis resources provided, mandated report, escalation, notifications]
• Disclosure rationale: [Justification if information shared for safety reasons]

(Include this subsection only when the contact was initiated due to safety concerns or if safety issues emerged.)

Assessment & Plan

Clinical Assessment: [How collateral information changes or clarifies formulation, diagnostic considerations, functional assessment, or barriers to treatment; consistency or discrepancy with patient self-report; impact on risk level with rationale]

Treatment Plan Impact: [Updates to goals, interventions, frequency, monitoring, or referrals; whether patient was informed and agreement status, or plan to review with patient]

Follow-Up Tasks:

• [Task] — [Owner] — [Timeframe] (Include contingencies if unable to reach or if risk escalates.)
• [Plan for updating patient and/or treatment team]

Signature: [Electronic signature with name, credentials, role, date/time]

(Template behavior: Create one note per discrete collateral event. If multiple attempts occur the same day for the same purpose, document as one note with the attempts log; create separate notes if content or recipients differ. Do not infer ROI existence, scope, participants, or disclosures—these require explicit documentation.)