What steps should a California psychotherapist take when a client is lost to follow-up?

Managing Lost to Follow-Up Clients in California Psychotherapy Practice

Primary Recommendation

When a California psychotherapy client misses an appointment or is lost to follow-up, you must actively attempt to re-establish contact through progressive outreach efforts—starting with phone calls, followed by written correspondence if needed—and document all attempts, as passive acceptance of dropout significantly increases risk of poor outcomes and may constitute abandonment of care. 1, 2

Immediate Response to Missed Appointments

First Missed Appointment

• Contact the client by telephone on the same day or within 24 hours of the missed appointment 1, 2
• Phone contact is significantly more effective than passive approaches, with clients who receive telephone follow-up being substantially more likely to attend their next appointment compared to those receiving no follow-up 2
• Document the date, time, and nature of your outreach attempt in the clinical record 3

If Phone Contact Fails

• Send a written letter or secure message within 3-5 days expressing concern about the missed appointment and offering to reschedule 2
• The letter should be non-punitive and express genuine concern for the client's wellbeing 1
• Include multiple ways for the client to respond (phone, email, patient portal) 1

For High-Risk Clients

• If the client has a history of suicidal ideation, severe mental illness, or recent crisis, escalate to a home visit or wellness check 2
• Home visits following failed appointments result in 100% attendance at subsequent appointments in high-risk populations 2
• Consider contacting emergency contacts listed in the treatment consent if the client cannot be reached and safety concerns exist 1

Progressive Outreach Protocol

Week 1-2 After Initial Contact Attempts

• Make at least 2-3 additional phone call attempts at different times of day 1
• Send a second written communication emphasizing your availability and willingness to address any barriers to treatment 1
• Offer flexible scheduling options, including evening or weekend appointments if feasible 1

Week 3-4

• Make a final documented attempt to reach the client, clearly stating that without response, you will need to close their case but remain available if they wish to resume treatment 3
• This communication should include referral resources for alternative care options 3
• Document that you have fulfilled your duty to avoid abandonment 3

Special Considerations for California Practice

Tarasoff Duty Implications

• If the client was lost to follow-up while presenting ongoing danger to an identifiable third party, you maintain your duty to warn/protect under California law 4
• Document your risk assessment at the time of last contact and any protective actions taken 4

Documentation Requirements

• Record every contact attempt with specific dates, times, methods used, and outcomes 3
• Document your clinical reasoning for the intensity of follow-up efforts based on the client's risk level 1
• Note any barriers to treatment the client mentioned in previous sessions that might explain the dropout 1

Risk-Stratified Response

High-Risk Clients (Suicidal, Psychotic, Severe Mental Illness)

• Attempt contact within 24 hours of missed appointment 1, 5
• Make at least 3 phone attempts over 1 week 5
• Consider home visit or request wellness check through emergency services if no response after 1 week 2
• Contact emergency contacts if safety concerns are acute 1

Moderate-Risk Clients (Stable but Chronic Conditions)

• Contact within 48 hours of missed appointment 1
• Make 2-3 phone attempts over 2 weeks 2
• Send written correspondence if phone contact fails 2
• Offer telehealth options to reduce barriers 1

Lower-Risk Clients (Stable, Near Treatment Completion)

• Contact within 3-5 days 1
• Make 1-2 phone attempts 2
• Send one written communication 2
• Document case closure timeline if no response after 3-4 weeks 3

Common Pitfalls to Avoid

Never Assume Client Disinterest

• Clients who receive no follow-up after missed appointments are significantly more likely to require emergency services rather than routine care at their next contact 2
• Dropout often reflects barriers to care (transportation, financial, stigma) rather than lack of motivation 1

Avoid Coercive Communication

• Do not threaten case closure as punishment for missed appointments 1
• Frame outreach as concern for wellbeing, not compliance enforcement 1

Don't Rely on Single Contact Method

• Some clients may not check voicemail but respond to text or email 1
• Offer multiple communication channels while respecting HIPAA requirements 1

Never Close Cases Prematurely for High-Risk Clients

• Maintain active outreach for at least 4 weeks for clients with serious mental illness or recent suicidality 1, 5
• Consider keeping the case open with periodic "caring contact" attempts (monthly postcards or brief calls) for up to 12 months for clients with recent suicide attempts 5

Ethical and Legal Obligations

You have both an ethical duty to avoid patient abandonment and a legal obligation to document reasonable efforts to maintain continuity of care 3

• The APA Ethics Code requires psychologists to provide for continuity of care and avoid abandonment 3
• Passive acceptance of dropout without documented outreach attempts may constitute abandonment 3
• Your documentation should demonstrate that you made reasonable efforts proportional to the client's clinical needs and risk level 3

When to Formally Close the Case

• After 4-6 weeks of documented unsuccessful contact attempts for lower-risk clients 3
• After 8-12 weeks for higher-risk clients with ongoing monthly contact attempts 5
• Send a final letter documenting case closure, offering to resume treatment if they contact you, and providing alternative referral resources 3
• Maintain records according to California retention requirements (minimum 7 years for adults, longer for minors) 3