AMI question regarding mental health records


New Member
Jul 18, 2017
DD received an administrative AMI request regarding anxiety. She went through a rough patch last summer, and she mentioned her anxiety symptoms to her pediatrician, who referred her to a counselor. She saw the counselor three times (and also read the DARE response book, which was far more helpful). She has been fine since.

The initial request specified medical records, and we provided the pediatrician office note about the counselor referral. Not very meaty, but there just wasn't anything else. (The counselor said she wasn't a medical provider, so this didn't apply to her.)

Now DODMERB responded with a request for ALL mental health/medical treatment and/or hospitalization records. That would seem to apply to the counselor.

The counselor has no experience with this sort of thing (like us!) and she said the only documentation she has is her session notes, which she ordinarily won't even share with the patient because they contain her immediate impressions, not a considered opinion/diagnosis. We've asked her to provide a short written summary of her assessment of DD and intend to submit that along with DD's thorough and honest personal statement about her anxiety history.

QUESTION: what level of detail should the counselor provide in her summary, or is she obligated to turn over her unredacted session notes? Any guidance on how to respond?