Effective Date: 
Mon, 08/22/2011
Mon, 05/07/2018
Thu, 01/11/2018

In certain clinical situations, a CAPS clinician may want to institute a police welfare check when they are concerned about the imminent safety of a client.  A police welfare check is a process by which law enforcement can go to an individual’s residence, place of work, classroom, etc. in order to determine if a person is in significant distress or in need of assistance because of a health condition.  A CAPS staff member may request that a welfare check be conducted for high risk clients who, in the clinician’s judgment, may be at imminent risk to themselves or others.   A Release of Information is not needed when requesting a welfare check for the imminent safety of the student or others.

In order to initiate this process, the following steps are followed:

  1. The treating clinician will consult with a licensed senior staff member of management team member prior to contacting the police.
  2. If the student lives in on-campus housing, the UCSC campus police are contacted to conduct the welfare check
  3. If the student lives in off-campus housing, the Santa Cruz city police are contacted to conduct the welfare check.
  4. The consultation and contact with the appropriate police department will be documented in the clinical record.


Effective Date: 
Fri, 08/01/2008
Tue, 04/17/2018
Tue, 04/17/2018

Clients are entitled to receive or review their record when this is "in their best interests" and would not be likely to cause "substantial harm."  The clinician reviews the record to determine if anything in it would, in her/his judgment, likely cause "substantial harm" as indicated by tangible and serious negative outcome, e.g. injury to self or others, not just emotional upset. Records are released in accordance with professional standards and regulatory guidelines.


1. If a client requests a copy of their record they must follow the procedures listed below:

i.       The client is required to request the records in writing and must sign a release of information form.

ii.      CAPS will, if appropriate, provide the client with a summary of their records or the entire record if requested.

iii.    If providing the records is deemed inappropriate CAPS will, after court order or request of the client, forward a copy of the records to a licensed mental health professional designated by the client

If the likelihood of harm as a result of disclosure may not be satisfactorily addressed through a staff person reviewing the records with the individual then:

1.)     The denial and reasons for it are reviewed with the individual; and

2.)     The denial and reasons for it are noted in the individual's record.

iv.     If a client wishes to see their records after they have read the summary and it is deemed appropriate for them to do so they may read the file in the presence of the CAPS Director or designee.  A copy of the file may be made at the client's expense.

2. Time guidelines for release of records:

i. Review of records-Five working days

ii. Treatment summary-Ten working days

iii. Copy of records-Fifteen calendar days

iv. Complex treatment summary-Thirty calendar days

3. Legal Consultation:

i.   UCSC employs a campus council.  In the event a CAPS staff member has a legal concern regarding a records request, subpoena, or other matter, they are to bring it to the attention of the CAPS Director.  The CAPS Director will either secure the requested information on the staff member's behalf or arrange a direct consultation between the staff member and the campus council.


Effective Date: 
Fri, 08/01/2008
Tue, 05/15/2018
Tue, 05/15/2018
  1. All clinical interactions with patients are documented by CAPS professional staff with a signed, contemporaneous note in the medical record in accordance with professional standards and regulatory guidelines.
  2. Clinical documentation is accurate and completed in a timely manner.
  3. Clinical records are maintained in an electronic medical record with security features that preserve privacy but allow timely viewing by health care practitioners with appropriate permissions.
  4. Unlicensed staff and trainees require the co-signature of their supervisor for all clinical documentation.
  5. The electronic record provides the time and date when notes are electronically signed. Notes written on a subsequent date are dated with the actual date of signature, even if referring to an earlier interaction. 

1. Crisis Notes:

  • Licensed Staff-Crisis services provided by licensed staff need to be documented within one working day.
  • Unlicensed Staff- Crisis services provided by unlicensed staff need to be documented within two working days, to allow time for review by licensed staff.
  • 5150 cases-If a student is involuntarily psychiatrically hospitalized from CAPS, documentation must be completed by the end of the day.

2. Non-Crisis Notes

  • Licensed Staff
    • Initial assessments must be completed within three working days of the service
    • Follow-up notes must be completed within two working days of the service
  • Unlicensed Staff- Review of the record and co-signature by supervisor for non-crisis services must occur within 5 working days of providing the service.

3. ADHD Assessments

  • Due to the time needed to complete, review, analyze, document, supervise, and co-sign the results of an ADHD assessment, staff have 10 working days from completion of testing to finalize documentation.


4. Content of clinical entries include, at minimum:

  • Date of service
  • Provider name and title
  • Chief complaint or nature of visit, with appropriate history
  • Objective clinical findings
  • Diagnosis, assessment or impression
  • Treatment plan documentation
  • A history of serious suicide attempt(s), dangerousness to others, or major alcohol/other drug (AOD) problem(s) are documented in the Clinical Comment section with the following codes, with reference to the date of a CAPS note that describes the problem:
    • History of serious suicide attempt(s) or dangerousness to others: “SUI (see x/x/xx note)
    • Major AOD problem(s): “AOD (see x/x/xx note)
  • Therapies administered or recommended with discussion of necessity, risks, and alternatives as appropriate

 5. Initial assessment/first follow-up notes will include:

  • Relevant history including- history of present illness, history of past psychiatric, medical and substance use problems, brief family history, academic/employment history
  • Mental status examination
  • Risk of harm to self or others
  • Known or potential addictive behaviors and substance abuse
  • Client self-understanding, motivation, and decision-making
  • Diagnosis, assessment, or diagnostic impression
  • Plan, including any medications prescribed.

6. A new first follow-up should be completed if it has been more than one year since the last visit. At the clinician’s discretion, a first follow-up note may be added to the chart when a student sees a new provider, or if there has been a significant lapse of time or change of condition since the last visit.

7. Termination of services will occur under the following circumstances:

  • Mutual agreement between provider and student
  • Student referred for off-campus treatment
  • No further contact is received from the student after outreach

8. Termination will be documented in the student’s EHR and will include:

Dates of service, diagnosis or diagnostic impression, level of risk at last contact, treatment administered, number of sessions, change in symptoms, disposition, and any final revisions to the Clinical Comment entries made by CAPS.

A clinical record can be terminated when the treatment is completed or at the end of the academic year at the discretion of the clinician.  Cases are terminated when students leave the university, treatment is completed, treatment is transferred to a provider off-campus, or are no longer eligible for services through CAPS.

Written terminations are done for individual therapy.  For group, a summary can be provided in the last group documentation.   If only an intake was conducted, a case management note for termination is sufficient.

Formal terminations are not required for psychiatric services as they are open-ended and students often start and stop treatment.  Psychiatric staff can choose to complete a termination form.

9. Telephone contact with a patient is clearly identified as such in the medical record and content of the call is noted in the EHR, with appropriate clinician signature.

10. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case follow the Medical Records Standards policy & procedure: XI. Corrections and Amendments to Records

11. Messages about clients to other CAPS staff are sent using the secure message system. The secure message system has more stringent security features than campus email.  Campus email is not used for protected health information.

12. Security of Mental Health Records - Health practitioners lock the computer screen prior to leaving the treatment room and screens automatically time out after 5 minutes if they inadvertently forget to lock the screen. Reminders to lock the screens are found on the work station. Paper protected health materials are collected throughout the day and locked up at the end of each day in the alarmed medical records office.

Key Points: 


  1. Documentation of clinical care occurs in the patient’s electronic health record.
  2. Documentation occurs in a timely manner, using standard clinical format.
  3. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case the medical records administrator can clear a note from an EHR.
  4. Security features to assure the safety of protected health information include the lock-out features in the EHR and regular collection of paper materials for storage in the locked Records office.





Effective Date: 
Fri, 08/01/2008
Mon, 05/07/2018
Fri, 05/29/2015


  1. In order for a student to be given a summary of services inclusive of a clinical opinion to a third party, the clinician must believe he/she has had enough time to form an accurate clinical impression of the student.
  2. CAPS staff can document client behaviors, clinical observations, symptoms, or prognosis to a third party with the appropriate release of information.  However, CAPS staff does not make recommendations about administrative concerns or decisions.  This would include decisions about academic status, removal or separation from school, housing or dining hall contracts, or participation in extra-curricular activities.
  3. CAPS staff should consult with a CAPS Management staff if providing documentation to third parties outside of the University related to background investigations, career, job, or internship acceptability, or appropriateness for certain job activities.
  4. When requests come from former clients regarding release of information pertaining to counseling services, standards of practice are used including obtaining informed consent and completion of Request of Information form from the client.
  5. CAPS staff who are licensed may submit clinical documentation to the Disability Resource Center (DRC) for students requesting academic accommodations if the clinician believes he/she has had enough time to form an accurate clinical impression of the student.  A consent for release of information must be obtained.
  6. CAPS staff who are licensed may submit clinical documentation for students requesting a medical leave (Request for Medical Information form) if the request is appropriate.
  7. Unlicensed staff and trainees must consult with their supervisor or another licensed staff member before submitting any documentation and documentation must be co-signed by the designated supervisor.





Effective Date: 
Fri, 08/01/2008
Mon, 05/07/2018
Fri, 06/13/2014

Referrals to private practices in which CAPS clinicians may have personal or financial interest represent a potential conflict of interest. It is important to avoid both actual conflict of interest and the appearance of impropriety in making referrals. The CAPS Center may refer a UCSC student to a UCSC-employed clinician’s private practice, or to a practice in which a UCSC-employed clinician has a financial interest, when all of the following conditions are met:

  1. The care for which the student is being referred is not normally available at CAPS.
  2. The clinician has provided the student with the names of at least two other appropriate practitioners, not associated with the University, in private practice in the community.
  3. Self referals are not permitted.
  4.  Referals to near relatives are not permitted.

NOTE: For more information on the University of California Conflict of Interest Code, see or



I, _________________________________________, wish to seek psychiatric/psychotherapeutic care off campus.(name of student)

I wish to see _________________________________________ in his/her private practice.
(name of clinician)
I am aware that the UCSC CAPS will not pay for this service, and is not responsible for care provided in the private practice setting.


Effective Date: 
Fri, 08/01/2008
Wed, 03/07/2018
Wed, 03/07/2018

As part of our mission to provide quality care and a safe place for students, staff and visitors,we monitor incidents that could result in harm to anyone working or visiting Counseling and Psychological Services (CAPS). An incident report is created anytime there is an unexpected occurrence involving patient, staff or visitors.  In addition, incident reports are created for adverse events such as actual breaches in care, administrative procedures or other events resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service. Any process deviation for which a recurrence carries a significant chance of a serious adverse outcome or events that could have resulted in an adverse event should be reported as an incident report. The online reporting system, RL Solutions, is to be used to document incidents for the purpose of quality assurance monitoring and continuous quality improvement. The Opportunity for Improvement form will be used to identify potential system problems before they compromise care or cause harm and to improve and revise policies and procedures as needed.

Examples of events which would trigger an Incident Report in RL Solutions include the following:

  • Dissatisfied or angry patient requesting to speak with a supervisor/manager due to care resulting in harm or potential harm.
  • Completed suicide or serious attempt resulting in significant injury.
  • Activation of emergency procedures (resuscitation, 911 emergency calls, use of panic button)
  • Injury to patients/visitors (Fainting, fall, unsafe situation)
  • Possible procedural error
  • Quality of care issue raised by patient
  • Quality of care issue raised by staff member
  • Child abuse or elder/dependent abuse report
  • Tarasoff situation

Any staff member can enter an incident in RL Solutions.  All incident reports are reviewed by the CAPS Director and/or Senior Associate Director as indicated. The incident reports are distributed to appropriate managers for review and investigation, if indicated. Incidents are reported back to the CAPS Director with recommendations to prevent future recurrences if the event was related to quality of care or safety issues that could potentially benefit from additional preventive measures. Individual staff members involved in incidents are provided specific feedback as appropriate. The incident report is not to be filed in patient’s mental health record. To ensure confidentiality, students should be identified in RL Solution reports only through the Student ID# and initials.  Date of Birth, which is a required field, should be made up.  The correct age can be manually entered to override the default.

The Opportunity for Improvement form can be used when there is a minor error that results in no student or staff harm.  Examples would be PHI left out in a locked office that only staff have access to, inadvertent documentation in the wrong student chart that is noticed and corrected immediately, or inadvertent access to a student chart without a clear reason to do so. These forms are reviewed internally by CAPS Management with feedback given to staff member as indicated.  The form is then submitted to the Medical Director for aggregation and reporting out to the SHS Quality Management Committee.

In an effort to ensure adequacy of evaluation and consideration of the least restrictive measures, when students are hospitalized from CAPS, either voluntarily or involuntarily, a hospital transfer form  is completed by the clinician or management team member involved and reviewed by the CAPS management team within one week of the hospitalization.  Reasons for hospitalization and 5150 documentation (if applicable) are reviewed. If indicated, the involved clinician is interviewed.   A summary of these situations is created by the SHS Quality Management Committee. The summary only includes number of transfers and whether the transfers were judged to be appropriate. No PHI or identifying information is communicated.



Effective Date: 
Fri, 08/01/2008
Mon, 05/07/2018
Thu, 01/11/2018

1.  Committees

The standing committees, ad hoc committees, and staff meetings are organizationally important components of CAPS.  These committees and meetings are responsible for much of the planning and implementation of the programs and services delivered by CAPS.  Although the tasks of the committees vary, all of them support the mission of CAPS.   The standing committees are: Clinical Quality , Training, Multicultural, Staff Development, and Management.  The regularly scheduled meetings are General Staff meetings for the entire CAPS staff,  Senior Staff meetings for senior staff, Continuing Education Committee and Management Committee.  The tasks of the Committees and meetings are described below.

a.       Clinical Quality Committee:Meets at least once a month or more often as needed to review all policies and procedures of all the services provided by CAPS, as well as studying new programs, and addressing identified systemic issues through empirical studies.  The goal is to ensure compliance with APA Ethical Standards, the legal mandates of the state of California and Federal laws, and ensuring continuous quality improvement.  Chaired by the Director and includes the Senior Associate Director, and at least one senior staff and one intern. This falls under the protection of the California evidence Code 1157.
b.      Training Committee:   meets twice a month to discuss intern and postdoctoral fellow issues, training policies, intern and postdoc recruitment, and administrative concerns. Chaired by the Training Director with senior staff.
c.      Management Committee:Meets regularly to discuss CAPS policies and procedures, legal/ethical issues, and other issues related to the management of CAPS services and programs.  Chaired by the Director and includes the Senior Associate Director and Director of Psychiatry when available.

d. General Staff Meeting

The entire CAPS clinical staff, postdoctoral fellows, and interns, and rotating front office staff meets weekly to address administrative and programmatic issues.

e. Senior Staff Meeting

Meets as needed to discuss administrative and programmatic issues affecting the senior staff.

f. Multicultural Committee

Chaired by a senior staff member, the multicultural committee meets monthly to address cultural competence and develop training opportunities for staff.

g. Staff Development

Meets monthly to address staff satisfaction and morale issues.  The committee organizes team building and other staff development activities.

h. Continuing Education Committee

Meets as needed to discuss the educational goals of the Center, and propose and arrange for educational programming. This committee works in conjunction with the Multicultural Committee and CAPS Management.


Effective Date: 
Fri, 08/01/2008
Mon, 05/07/2018
Thu, 01/11/2018

CAPS conducts quarterly satisfaction surveys each of three quarters during the academic year.  All students seen within a designated time period are sent an electronic questionnaire.  Results are analyzed and feedback given both on an individual and departmental basis as indicated. Results are analyzed by the CAPS Clinical Quality Committee and also presented to the SHS Quality Management Committee.


Effective Date: 
Fri, 08/01/2008
Mon, 05/07/2018
Mon, 06/26/2017

A Third Party Consultation involves someone who walks in or calls in because they are concerned about a student.

Third Party Contacts – Communications of concern about a student who may or may not be currently receiving services at CAPS, from someone who knows the student.  This could be a parent or other relative, friend, Resident Advisor, Academic Advisor, professor, or anyone else who has sufficient knowledge of a student to determine he/she could be in some sort of distress. If a release of information is in place on a student who is currently in treatment, information gleaned from the contact should be documented in a Case Management note.  If not, documentation should be in a third party note. Information received from a treating medical or mental health provider should be documented as a Case Management note.

Who is eligible to receive CAPS consultation?

a.       Any member of the UCSC community can request consultation, including faculty, staff, family, or friends of UCSC students in distress

b.      On occasion, CAPS provides consultation to members of the Santa Cruz community or non-local psychotherapists seeking referrals or information about CAPS services

c.       Consultation can be provided either in person or over the phone

What might consultation address?

a.       Information about CAPS services and accessing services

b.      Referral questions

c.       How to help a distressed student - staff, faculty, friend, family member, roommate

               d.       Assistance in program planning

  • When third party contacts walk in or call in to the CAPS Front office, they are to be directed to the crisis service. If the crisis staff is not available, calls should be sent to a member of the management team.
  • When third party contacts walk in or call  Primary Care services, support staff transfer them or direct them to call CAPs main phone line.  Primary Care Clinicians (MD/NP/PA) may choose to make a third party entry themselves.
  • When a CAPS staff member or trainee is contacted by a campus community member seeking consultation, the first step in the consultation process is to check the Electronic Health Record to determine if the student has been seen as a client at CAPS.  Confirm if any Releases of Information are on file.
  • ​If the student is in current treatment at CAPS, when possible, it is incumbent upon the clinician to seek consultation from the psychologist or psychiatrist who has been the treating therapist before consulting with anyone about the case.
  • If the student had previous treatment with an off campus provider, and it is in the best interest of the client, CAPS staff members should consult with previous off campus providers when clinically appropriate.  A Release of Information must be on file to proceed with consultation.
  • ​All Third Party contacts should be documented in the Third Party Security Division of the student's Electronic Health Record.  There are specific templates available for third party contacts.
  • ​When initial contact is made with a student, clinicians should review any previous Third Party contacts to determine if any concerning patterns exist.  If clinicians are contacted directly by a third party (not through crisis service) the same procedure of documentation applies.  If students are seen in the center subsequent to documented third party contacts, these contacts should be included in the assessment of the student and could be incorporated into the clinical record if the clinician deems this appropriate.  Third party contacts are not part of the mental health record and would not be released in the event a valid request for release of mental health records was received.
  • ​CAPS will document and monitor third party contacts and reach out to the student, if, in the judgment of the clinician, the reported behavior(s) warrant(s) concern.  Outreach could result from one highly concerning call or a series of more minor concerns that are adding up to a problematic pattern of behavior.



Effective Date: 
Fri, 08/01/2008
Fri, 03/16/2018
Fri, 03/16/2018

Case Management (provided by Case Managers): Services supporting the treatment or disposition of a student including facilitating referrals, coordinating with support systems, advocacy, or accessing necessary resources.  This service may include brief therapy in addition to the aforementioned services.


1)      Criteria for determining who qualifies for Case Management services.

a.       Students released from psychiatric hospitalization within the last three months.

b.      Students who are experiencing barriers, or need extra support, in accessing community resources, or have been unsuccessful two or more times with their primary provider's help.

c.      Cases involving multiple units and providers, on and/or off campus.

d.      Frequent use of crisis services (2-3 times per quarter), though not in crisis, and difficulty following through on suggested resources.

e.       Psychiatry case management referrals can be for a variety of issues, including referrals to on or off campus psychiatry.

f.      Other cases TBD on a case-by-case basis in consultation with the Case Manager Supervisor.

2)      Students may continue to receive Case Management services for as long as determined appropriate by the Case Manager and primary clinician.

3)      Procedure for referral for case management services.

a.       Students who meet the above criteria can be referred after consultation with the Case Manager or Case Manager Supervisor regarding appropriateness of the referral.

b.      Send an instant message to the Case Manager or Case Manager Supervisor indicating eligibility, risk factors, disposition and case management needs.

         i.      If sending the instant message to the Case Manager Supervisor, they will assing a Case Manager to the student based on the needs of the student, and Case Manager's schedule.

c.       The appointed Case Manager may contact the student to schedule an appointment, if necessary, or otherwise may work with the student through phone contact or secure messaging.  Additionally, s/he may provide resources and/or consultation with the referring provider.  The Case Manager will contact the student only after the primary therapist, or provider, has informed the student of the Case Manager’s role in his/her treatment.  If possible, the provider will introduce the student and the Case Manager prior to initiation of Case Management services.

d.      The Case Manager will consult with the current clinician, psychiatrist, and/or PCP, throughout the case management process as needed.

4) Case Management services are documented in the student’s Electronic Health Record.

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