Identify Relevant Sources of Information in Records at the Outset of the Case

When you open a case file for a new client, one of your first moves should be to gather and review existing records. Medical notes, school documents, prior behavioral assessments, medication lists, and legal paperwork all contain crucial information that shapes your assessment plan, protects client safety, and saves time. Yet many clinicians defer this step or handle it haphazardly—and that delay costs you later.

This article walks you through how to identify relevant record sources early, why it matters for safe and efficient practice, and how to do it ethically and thoroughly.

One-Paragraph Summary

At the outset of a case, identifying relevant sources of information in records means systematically locating and requesting all documented history that affects your client’s current behavior, safety, and learning—such as medical history, educational records (IEPs, 504 plans), behavioral assessments, medication lists, incident reports, and prior intervention notes. The goal is to gather this information before you conduct your formal assessment, so you can design an efficient, safe, and targeted evaluation plan; avoid duplicating assessments another provider has already completed; spot contraindications (like a new medication that might explain sudden behavioral change); and respect the client’s and family’s time by building on what is already known. Requesting records early also helps you understand baseline functioning, prior treatment responses, and key stakeholders—all of which inform your initial consent discussions and opening conversation with caregivers. In short: start your record-gathering at intake, prioritize documents tied to current concerns, and document every step.

Clear Explanation of the Topic

What It Means to Identify Relevant Record Sources

When you identify relevant sources of information in records at the outset, you are actively locating existing documents about your client before you begin assessment or intervention planning. This is not passive. You are not waiting for records to arrive; you are determining which records exist, who holds them, and how to request them within the first few days or weeks of client contact.

Think of it as building a map of your client’s documented history. Your map should include:

Clinical records (medical exams, hospitalizations, diagnoses)
Educational records (IEPs, standardized test scores, classroom progress notes)
Behavioral records (prior ABA notes, behavior incident reports, teacher observations)
Developmental history (early intervention records, speech/PT evaluations)
Medication information (current prescriptions, side effect notes, changes)
Supports already in place (speech therapy, physical therapy, school accommodations)
Legal records (custody orders, court reports, probation notes if applicable)
Prior formal assessments (psychoeducational testing, autism evaluations, ADHD assessments)

Who Holds These Records and How Access Works

Different organizations keep different pieces of the puzzle. Your client’s pediatrician or family doctor holds medical records. The school district holds educational records. Prior ABA providers keep progress notes and assessment files. Hospitals, mental health clinics, speech-language pathologists, and occupational therapists all maintain their own documentation. Family members may have informal records—photos, notes, early assessments—that are legally theirs to share.

To access these records, you generally need permission from the person authorized to give it. This is usually a parent or legal guardian for minors, and the client themselves for adults (unless there is a guardianship or power of attorney). The two federal laws you’ll hear about are HIPAA (which covers medical providers, mental health clinics, and some digital health systems) and FERPA (which covers schools). Both require written consent before records can be released. When in doubt, ask your clinic’s compliance officer or legal advisor about your specific obligations.

Records vs. Interviews and Observations

Keep clear the difference between records and the interviews or observations you will conduct. Records are documented history—something already written down, filed, and accessible. They are snapshots of what someone wrote at the time; they reflect that person’s training, perspective, and what they chose to note. An IEP, a medical note, a progress chart from a prior provider—these are all records.

Interviews and observations are primary data you collect yourself. When you call a teacher and ask, “Tell me what you see when this student gets frustrated,” you are gathering collateral information through an interview. When you sit in a classroom and watch the student during transition, you are observing. Both are essential, but they serve different purposes. Records give you historical context; your own assessment gives you real-time, standardized, direct information.

Why Timing Matters: The Intake Window

The reason to do this at the outset is simple: the sooner you have the full picture, the sooner you can plan intelligently. Intake is your window to ask foundational questions. Once you are deep in assessment, it is much harder to pause and wait for old records to arrive.

If you request records after you have already started testing, you may learn halfway through that the client was on a different medication last month, or had a major life event, or has a prior diagnosis that changes how you interpret your findings. You may even find that someone else already did a thorough ABA assessment two years ago, making much of what you are about to do redundant.

By requesting records early—ideally during your first phone call or intake meeting—you set yourself up to write a smarter assessment plan, choose the right measurement tools, and avoid wasting the client’s time and your own.

Why This Matters

Speed and Safety in Case Formulation

Early record review accelerates your path to a sound case formulation and reduces the risk of missteps. When you have medical history, you can spot whether the client has a condition (epilepsy, cardiac disorder, diabetes) that affects behavior or requires precautions during intervention. When you see a medication list, you learn whether a new drug was added right before the behavior problem started—which might suggest the behavior is a medication side effect, not a learned behavior you need to address (or it might be both). When you review prior ABA notes, you discover what reinforcers have worked, what extinction bursts looked like, and what the client’s learning rate actually is.

Avoiding Duplicate Assessment

One of the biggest wastes in behavioral health is re-assessing a client on something another clinician already assessed thoroughly. If a school psychologist did a comprehensive functional behavior assessment last year, and you are now seeing the same student in a clinic, you don’t need to repeat the whole thing from scratch. You can review what they found, build on it, and focus your assessment on the new concerns or the new setting. This respects the family’s time and is more efficient for you.

Identifying Contraindications and Prior Responses

Records also help you spot safety flags. If a client has a history of elopement and prior interventions triggered aggression, you need to know that before you design a plan. If a family tried a particular reinforcer and the child had a severe allergic reaction, you need to know that. If a client is on a medication that causes drowsiness, and a prior ABA provider noted that the client’s engagement dropped at 3 PM, that’s valuable context. These details live in records, not in verbal reports alone.

Ethical and Relational Value

There is also an ethical dimension. Asking for records and actually reading them tells the family and the client, “I take your history seriously. I am not starting from scratch as if nothing came before.” It builds trust. It shows respect for the time and money they have already invested in previous care. And it grounds your assessment in informed consent—because to truly get informed consent, you need to understand the client’s baseline, medical status, and prior experience with interventions.

Key Features and Defining Characteristics

Timing: Request Early, Before Formal Assessment

The best time to request records is at your first contact—during the intake phone call or at the initial meeting. At minimum, request them before you sit down to write your assessment plan. If you are the clinician conducting the first assessment, do this before the first session. If you are a supervisor or director overseeing intake, make it policy that every intake coordinator requests records within 48 hours of a new referral.

Breadth: Include Formal Reports and Informal Documentation

Relevant records are not just official reports. Yes, prior neuropsychological testing counts. So do an IEP, a school progress monitoring chart, or a prior ABA progress note. But also include informal documentation—an email from a teacher describing a behavior incident, a note a parent wrote about when the behavior started, incident reports from a day program, or nursing notes from a residential facility. Anything written down that reflects observations or history is worth reviewing.

Relevance: Focus on What Affects Current Concerns

You do not need to request every record that exists. Narrow your focus to documents that plausibly affect the behavior, learning, or safety question you are trying to answer. If the referral is for behavior during transitions at school, request the IEP, current teacher progress notes, and behavior incident reports from school. If the referral is for sleep problems and the client has a complex medical history, request recent medical notes and medication lists.

Source Reliability: Weigh Official Reports More Heavily (With Nuance)

Not all records carry equal weight. A formal assessment written by a qualified professional—a school psychologist’s evaluation, a medical diagnosis from a pediatrician, a prior ABA assessment done by a BCBA—generally merits more confidence than a one-off note from someone without training. But even formal reports can be outdated, based on limited information, or written by someone who did not know the client well.

Read with a critical eye. If a record contradicts something else you are learning, do not just pick a winner; investigate. Call the person who wrote the report and ask what they were observing. Ask the family to clarify. Use multiple data points before you conclude something is true.

Documentation: Record What You Requested, Received, and Reviewed

This is a step many clinicians skip. In your case file, document the date you requested records, from whom you requested them, which records you actually received, and which ones are still pending or were refused. If you requested records and never got them, note that you made the request and follow up dates. If a family declined to release certain records, document that refusal. This is not busywork; it is a clinical and legal trail showing that you took record-gathering seriously.

When You Would Use This in Practice

At Intake and Triage

The moment a new referral comes in—whether by phone, email, or through a practice management system—your intake coordinator or the clinician taking the call should ask about records. “We’d like to request your child’s medical records, school IEP, and any prior reports from other providers. Can you help us with that?” This conversation happens at intake, not a week later.

Before Developing Your Assessment Plan

Once you are assigned to conduct the assessment, do not write your assessment plan until you have at least tried to obtain and reviewed key records. You may not have everything by the time you sit down to plan, and that’s okay—but you should have made the attempt and documented it.

When History Suggests Risk or Prior Interventions

If the referral mentions medication changes, prior aggressive episodes, elopement, or medical complexity, record-gathering becomes urgent. These histories often point to safety considerations or interventions that have already been tried.

During Transitions of Care

Whenever a client moves from one provider to another—from a school district program to a clinic, from an ABA provider to a new one, from residential care to a community setting—that is a natural moment to request and review records. This ensures continuity of care and prevents a loss of institutional knowledge.

Examples in ABA

Example 1: New Referral From a Pediatrician

A pediatrician refers a five-year-old for behavior concerns at home and school. At your intake call, you ask the parents if they can authorize release of the child’s medical records, the school IEP, and any prior evaluations from speech or occupational therapy. You send a simple form for the parents to sign. While waiting for records, you schedule the first parent interview, but you do not schedule direct assessment until you have reviewed what came in.

When the IEP arrives, you see the child qualified for services under autism, has sensory sensitivities noted, and is receiving speech therapy. The medical records show the child started a new ADHD medication three months ago. This tells you that medication side effects might be a factor, and you can ask targeted questions about timing. It also tells you the child has documented sensory needs, so you can design your assessment environment to account for that. You avoid replicating testing the school already did, and you coordinate your recommendations with the IEP team.

Example 2: School-Based Referral

A middle school requests ABA support for a student with explosive behavior during academic work. Before you observe in the classroom, you request the IEP, current progress monitoring data, classroom behavior logs from the past semester, and incident reports.

The IEP shows the student qualified under emotional/behavioral disorder and has a behavior intervention plan written two years ago. The behavior logs show that incidents spike on Fridays and during math. Incident reports describe specific triggers (corrections from the teacher, requests to redo work).

This documentation tells you where to focus your observation—math class, teacher-student interactions around corrections—and helps you avoid redundantly assessing things already captured in the behavior logs. You can align your measurement with theirs to make progress tracking continuous.

Examples Outside of ABA

Example 1: Physical Therapy

A physical therapist receives a referral for a patient post-knee surgery. Before the first session, the therapist requests and reviews the surgical notes, the orthopedic surgeon’s discharge summary, and recent X-rays. The notes reveal that the surgeon repaired a torn ACL and medial meniscus, the patient was instructed to avoid pivoting for 12 weeks, and range-of-motion restrictions were noted.

The therapist uses this information to set realistic milestones, avoid unsafe movements, and coordinate care with the surgeon if complications arise. Without those records, the therapist might push too hard too soon or duplicate range-of-motion testing the surgeon already did.

A social worker opens a family case following a child welfare referral. Before meeting with the family, the worker requests prior case notes, custody orders, and any court reports. These records show prior substantiated neglect, an ongoing custody dispute with a non-custodial parent, and a prior safety plan that was closed 18 months ago.

This history shapes the worker’s assessment priorities, informs which family members can and cannot be present at meetings, and highlights which risks to monitor. Without these records, the worker might miss a legal constraint or repeat a mistake from a prior case.

Common Mistakes and Misconceptions

Mistake 1: Treating Verbal History as Complete Documentation

A caregiver tells you, “My child has never been evaluated before,” or “We don’t have any old medical stuff.” But records exist whether or not the caregiver remembers them. A prior visit to an occupational therapist three years ago, a brief evaluation by early intervention, an allergy test—these are records, and they may be filed somewhere the caregiver did not think to mention. Do not assume verbal report equals complete history. Actually request records in writing and ask the family to help you locate them.

Mistake 2: Waiting Until After Assessment Begins

If you start your assessment without having made a genuine attempt to obtain records, you risk building your plan on incomplete information. You may design a comprehensive FBA only to discover halfway through that the school already did a detailed functional assessment last year. Request records before you launch assessment, not afterward.

Mistake 3: Not Documenting Attempts

If you called a pediatrician and left a message requesting records, and they never called back, write that down. “Called Dr. Smith’s office on 3/15; left voicemail requesting medical summary. No response as of 3/20.” If a school says records are “in the mail,” note the date you called and follow up in writing. This trail protects you and ensures that future clinicians know what you attempted.

Mistake 4: Confusing Records With Collateral Interviews

Requesting an IEP document is not the same as calling the teacher for an interview. The IEP is a record. An interview with the teacher is primary data collection—you asking questions and capturing their perspective. You need both, but they are different activities. Do not assume that reading a record means you have “gotten information” from that person. You still may need to interview them to clarify, update, or dig deeper.

Ethical Considerations

Before you request a single record, you need written permission from the person authorized to consent. You cannot request records “just to see what’s there.” You must explain to the family why you are requesting each record, how you will use it, and how you will protect it. Many clinics use a simple release-of-information form that lists common records and gives the family the option to approve or decline each category. This respects autonomy.

Explaining the “Why”

When you ask a family for permission to request records, do not just hand them a form. Explain in plain language why you need each record. “We’re asking for the school IEP so we can see what accommodations are already in place and coordinate our behavior plan with the school.” “We’d like the medical records so we know if there are any health conditions or medications that might affect behavior.” Families are more likely to consent and trust you if they understand the purpose.

Using Records Fairly and Accurately

Once you have records, do not over-interpret them. If a prior report says “behavior may be attention-seeking,” do not treat that as a proven diagnosis. It is a hypothesis someone formed. If a progress note says the client “made progress” but gives no specific data, do not assume what kind of progress. Read with an open mind, and verify unclear or surprising claims if you can.

Equity and Accessibility

Requesting records can place a burden on families—tracking down old providers, filling out consent forms, sometimes paying for copies. Be aware of this. Offer to help. If a family is struggling to locate records, call the providers yourself on their behalf (with consent). If a family cannot afford copy fees, ask your clinic if it can cover them. Do not let a family’s limited resources or language barriers prevent them from accessing services.

Once you have records, they become part of your client’s file and are governed by the same confidentiality rules as everything else you hold. Do not share them with anyone outside your treatment team without explicit new consent. If a family consents to you requesting records from a prior provider, that does not mean they have consented to you sharing those records with a third party.

Practice Questions

Question 1: A new client is referred for behavioral assessment. At intake, which of the following record sources should you request?

The correct answer is to request a mix of document types that address the presenting concern—for example, medical history and medication list (to rule out medical/pharmacological factors), prior ABA progress notes if applicable (to avoid repeating assessment), school IEP or progress notes (if school is a setting of concern), and incident reports (to understand behavior patterns). These multiple sources give you a fuller picture of baseline, prior interventions, and current supports, allowing you to design a targeted assessment plan. Limiting your request to only one or two categories risks missing important context.

Question 2: You request records during intake, but the family says they cannot locate the prior ABA provider’s notes. It is now two weeks later, and the first assessment session is scheduled for tomorrow. What should you do?

The correct answer is to proceed with interim safety planning while continuing to request records, and document your attempts. Note in the file that you requested prior ABA records on a specific date, that the family was unable to locate them, and that you attempted to contact the prior provider directly. Conduct your assessment as planned, but build in a note to follow up on records if they surface later, and be cautious not to make treatment recommendations that might contradict something in the missing notes until you have had a chance to review them. You cannot delay care indefinitely waiting for records, but you must document that you tried.

Question 3: You receive conflicting information: the IEP says the student has a “calm demeanor” in the classroom, but the teacher tells you in an interview that the student has frequent outbursts. How do you handle this?

The correct answer is to note the discrepancy, document the dates and authors of each report, and seek to understand why they differ. Ask the teacher what they are observing and when the IEP was written. Perhaps behavior has changed since then, or the IEP team witnessed different behavior than what the teacher sees daily. Gather more data through your own observation and measurement before concluding what is actually true. Do not assume one source is right and the other wrong. Use multiple data points and primary observation to build a more complete picture.

Question 4: A parent gives permission to request the child’s medical records, but declines to release school records, saying the school is doing fine and they do not want the school to know about the behavioral issues at home. What should you do?

The correct answer is to respect the parent’s refusal, document it clearly, and explain the implications. You might say, “I respect that. I can work with you on home behavior, and if at some point you feel comfortable sharing information with the school, we can do that.” Document that the parent declined school records release on a specific date and that you offered to coordinate with the school if the parent consents in the future. Consent must be voluntary, and families have the right to set boundaries. However, explain that this might limit your ability to ensure consistency across settings, and document the choice so future clinicians understand the constraint.

Functional Behavior Assessment: Records provide the historical context and prior hypotheses that shape your FBA scope and question design. If a prior FBA already identified a function, your new FBA can either validate those findings or test new questions.

Informed Consent: You cannot obtain true informed consent without understanding the client’s baseline, medical status, and prior experiences with similar interventions. Records review is part of what makes consent informed.

Collateral Interviews: Records and collateral interviews work together. Records give you documented history; interviews allow you to ask clarifying questions, understand context, and gather observations that may not have been documented.

Risk and Safety Assessment: Records are often the quickest way to identify prior safety risks (elopement history, aggression, self-injury, medical fragility) that shape how you design and deliver intervention.

Data Collection and Measurement: Aligning your measurement system with prior records (using the same definitions, measurement method, or baseline metric) allows you to demonstrate continuous progress and build on prior work instead of starting over.

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Frequently Asked Questions

Q: What types of records should I request first?

Start with records tied to the current referral question. If the referral is for behavior, request medical history, medication list, prior behavioral assessments, and IEP/504 plan. If the referral mentions a specific concern (aggression, elopement, sleep), ask for incident reports from that setting. If the client has a complex medical or psychiatric history, prioritize medical and medication records. Once you have the essentials, you can request additional records as needed.

Q: Do I need consent to request school records?

Yes. Schools fall under FERPA, which requires written consent from a parent or legal guardian (or the student if they are an adult or emancipated) before releasing educational records. A simple one-page form that lists the records you want and includes parent signature and date is usually sufficient.

Q: How long should I wait for records before proceeding with assessment?

Document your request and set a reasonable timeframe—usually 7 to 10 business days. If records have not arrived by then, send a follow-up request. If you are working with an urgent case, you can proceed with interim assessment and safety planning while continuing to request records. Keep trying, and keep documenting. Records often arrive late, and late is better than never.

Q: What if a family refuses to release certain records?

Respect the refusal and document it. Explain why you wanted those records and discuss what impact the refusal might have on your assessment. Offer to request records in the future if circumstances change. Obtain whatever information you can through other means, and note the limitation in your report.

Q: How do I handle conflicting information across records?

Document the discrepancy. Note the date each record was written, who wrote it, and what they observed. If possible, call the author and ask for clarification. Gather your own observational data to see which picture is more current. Do not assume one source is wrong; assume they may reflect different times, settings, or raters, and use multiple data points to form your conclusion.

Q: Are informal notes (emails, text messages) relevant records?

They can be, if they contain observations or history relevant to the client. An email from a teacher describing a behavior incident or a text from a family member documenting when a symptom started are informal records. Assess their reliability—an email is less formal than an official report. If you use informal notes, document where they came from and obtain permission from the person who wrote them before using them in a formal report.

Key Takeaways

Record identification is a foundational intake skill that protects your client, informs your assessment, and demonstrates respect for the client’s and family’s time and prior care.

Start by requesting records early—ideally at your first contact, and certainly before you design your assessment plan. Cast a wide net to include medical, educational, behavioral, medication, legal, and prior assessment records. Prioritize documents that directly address the current referral question, but do not skip record categories that might reveal safety flags or prior interventions.

Always obtain written consent before requesting or sharing records, explain to families why you need each record, and be transparent about how you will use and protect the information. Document every step: note what you requested, when you requested it, what you received, what is still pending, and what the family declined.

When records conflict or are unclear, verify with the original source rather than guessing. Use records alongside your own interviews and observations—they complement but do not replace direct assessment. Handle records with care; they are confidential clinical information, and how you obtain and manage them reflects your professionalism and respect for the families you serve.

The habit of systematic record-gathering takes time to build, but it pays off in faster, safer, smarter assessments and stronger collaboration with other providers and schools. Make it part of your intake routine, and you will find that your case formulation is richer, your assessment plan is more efficient, and your relationship with families deepens.