Providers: Don't forget to continue to document stable/lifelong disabilities

I am encountering documentation from a number of well-meaning providers who seem to be 100% following the social model of disability and the recovery model in their notes. Their notes focus entirely on what is important to the person and contain only positive comments.

While I very much support the overarching sentiment here, this type of documentation is not helpful, and can be harmful, when someone needs to document their disability for accommodations or benefits. I'm seeing notes for people who have significant functional deficits, but have figured out their life around these and aren't distressed by it, with absolutely no mention of these. I once completed an evaluation for a family with a teen who has some pretty significant support needs. As with most teens, this person stopped receiving any services around 10, as they had made all of the progress they were likely to make with communication, motor skills, and so forth. The documentation from these services was all framed positively and referred to the teen graduating from the services and having met all goals. The documentation from their ongoing medical providers reported they had graduated from these therapies without any further clarification. 

This teen was denied a number of case management and vocational support services, as the medical documentation indicated "doing great with everything."

Remember, most decisions around service eligibility are made by a someone who isn't a clinician, and if they are, they are usually a nurse or physician of a random specialty who isn't versed in developmental/rehab-type services. These people's viewpoint is usually that if someone wasn't doing expected things (working a typical job, independently taking care of household/community tasks, etc.), the ongoing providers would of course have documented this as a crisis and would have mandated intensive services to push those skills. 

My recommendation would be to ask the individual or family if they will be needing documentation at any point that documents their disabilities. If so, we might provide a periodic summary that lists what the person does not do or does with extensive accommodations, while keeping our notes in general focused on stability and quality of life when this is the case. I might write something more verbose that captures these dialectics, stating clearly that the person is unable to do X task due to Y conditions, though is fully able to meet their obligations by hiring people, living with someone, etc. We might also ask if the person finds it validating to have documentation that there are things they are unable to do; many disabled people are looking for this and find it helpful, provided it is done in a supportive manner. 

Also, remember that for minors, we need to be spelling out when functioning does not meet age norms. Most professionals who are not developmental folks (and certainly most non-clinicians who are determining eligibility) have no idea really how very early most skills occur in developmentally typical children. A number of non-normed checklist tools seem to operate on an idea that people are completely dependent for communication and self-care tasks until 18. Given how many children are carpooled and playdated thus not given opportunities for independence (yet have the motor and cognitive skills to easily learn these tasks if taught them), age norms are particularly important. If I state that a 10-year-old (who has had OT, whose parents have worked extensively on tasks due to the disabilities) is not independent with certain hygiene tasks, the child is likely to encounter gatekeepers whose thinking is that their most 10-year-olds cannot do those things. In this instance, it actually is more effective to use a normed ADL tool and state that hygiene skills are around an age equivalent of 5 years. If the child is using adaptive materials (checklists, color-coding, magnifying mirror, electric toothbrush, adaptive grips), I will state this, and the estimated age equivalent possible without adaptations. 

Additionally, we need to remember to ask about and document measures of functioning that are slightly outside of our usual area of focus, but aren't out of our scope. For instance, as LMHCs, while we might be seeing someone for anxiety around a specific issue, if they have an ongoing disability that means there are certain things they don't do, do with accomodations, or do differently than others, we should be documenting this. Reviewers are quick to note that our documentation did not mention that the person only travels with an aide when discussing anxiety in crowds, or takes paratransit to work when we discussed getting out the door on time. 

If we are working in settings that only require a comprehensive evaluation be done once (or don't really require it to be comprehensive), we need to make even more sure that our notes refer to things that haven't changed, but still aren't typical. Disabled folks will need to bring current records to school and work that document that they're still disabled. Professionals who are not developmental/rehabilitation folks don't understand that most skills for disabled folks don't change a whole lot after elementary school or so. I see reviewers saying that documentation described extremely impaired self-care abilities due to motor skills during an evaluation at 13, but the person is now 17 and isn't receiving services to work on motor skills, thus their inference is that the skills must be normal. 

I still have never figured out whether those checkoff lists for physical exams or mental status exams are looking for whether the item being assessed is typical, or is normal for the person. I can't tell you how many times I've seen physical exams that list an established diagnosis of hypotonia, then muscle tone is checked off as normal. Or vision is checked off as "normal" in a visually impaired person who presumably wasn't having double vision or any signs of acute problems. Some assessment forms used in community mental health (IYKYK) only have ways to indicate how much of a "problem" a particular skill area is.

I dealt with an issue in which a family had a youth who had been born with a limb difference, which hadn't been noted in any medical records other than at birth. The parents were high-functioning in terms of getting services they needed in place without involving their pediatrician, and the child and family had never raised any concerns about needing medical attention or assistance in getting accommodations for the limb difference. This doesn't seem like a problem on the face of it; no medical needs were present, and we should support body diversity, right? It did become quite a problem when something unrelated the child said was misinterpreted by a school staff member (a "my dad would kill me..." type comment), who decided to report to CPS that the child was being physically abused. CPS visited the home, found a child with a missing limb, requested medical records only from the pediatrician and not the specialists, and found that all of the physical exams listed "extremities: normal." 

Also, with a situation like this, while the Americans with Disabilities Act guidance discourages organizations from requiring documentation for accommodations when a disability is obvious, most places want "something on file." When they need to provide this documentation, this family should be able to download their child's last physical, which should list the limb difference and if the child uses any type of prosthetic.

Regardless, if we are going by "normal for the person," we need to put something in notes. If I'm seeing an autistic person who generally has a rather flat presentation that isn't concerning, I can check off "full range of affect" and "congruent facial expressions" if I am working somewhere that uses a prefabricated assessment, but then should put in notes "presentation is fairly flat at baseline, is nonconcerning, is appropriate for an autistic person." If I just check that it's normal, someone might review that note, meet the person, and deduce that it's new or unusual that they seem fairly flat. 

Remember, people in general are really ableist, and they expect that healthcare professionals especially share these worldviews. These people have a terrible time wrapping their minds around a note that describes someone as happy, healthy, and successful even when it does clearly spell out that the person does not walk or read. If we don't even document the things the person can't do, they will completely make up their mind that someone being described as stable and functional is obviously nondisabled. 

Disability nonprofits and other advocates: Stop promoting this idea that people should provide their own accommodations

I am getting quite frustrated with leading U.S. disability nonprofits platforming these parent-led initiatives that focus exclusively on parents providing their child's accommodations with absolutely no mention that this is to be a last resort when a program is not following the law and a family still wishes to be included. I'm seeing disability nonprofits posting on social media about parents spending extensive time modifying materials for extracurriculars and providing inservice trainings about their child's disability, and this is being promoted as normal and encouraged. I'm seeing things like "tips for success at summer camp for kids with [disability]" that focus on the parent providing all of the accommodations and modifications as well as the general staff training around disability, not just the training specific to their child's equipment and methods. 

Of course I am not going deny the reality that disabled folks and their friends and family frequently end up providing their own accommodations, nor am I going to suggest that any one individual should stop doing this in any particular situation. Of course people make the informed choice every day to provide their own accommodations so they can be included somewhere, and it would be ridiculous to suggest that someone forgo every service or experience just to make a point. All of us who have a less-common need or someone in our lives who does are all-too-familiar with the idea of "having a super low bar" and frequently settling for things that really aren't ideal. 

And of course it's a normal and natural part of interdependence that most disabled folks who go into a restaurant or museum with family or friends are going to have those people provide most of their accommodations such as reading things or reaching things rather than requesting that the staff do it. The point here of course is not that friends-and-family-as-accommodations is necessarily a bad thing. 

What's missing here though is that so many of these resources don't once mention that if you're in the U.S., and you're dealing with a business open to the public, the place most likely has to provide accommodations. There are only a few rare exceptions. Most businesses are not aware of these obligations, and frequently will ask someone to bring their own accommodations. They e-mail back someone stating they need to communicate in writing and say their business only uses the phone for that ("you'll need to have someone make the call for you then"). They state they don't have screen-reader-accessible versions of the forms they haven't updated in 20 years ("someone can help you fill it out"). 

The other thing with the ADA is that enforcement is difficult. In most cases, what people do is go somewhere else or provide their own accommodations. I don't begrudge anyone for not formally pursuing ADA violations. 

However, I also am a behavior science person. I can tell you with a high degree of certainty that most people are not in the habit of just doing whatever the hell they want until someone in authority stops them. Most people overall want to do what's good and helpful and prosocial, but also tend to do what's normative and what's been modeled for them.

If someone works at a summer camp and their experience is that disabled kids have their parents provide all the accommodations and train their staff, they have no reason to understand that this is unjust and shouldn't be happening. There is no reason most people would know that the ADA obligates any public place to spend some degree of time and money to put accommodations in place -- even if they looked at most of the ADA materials put in place by the government and nonprofits, these are mostly about structural access requirements and they're going to believe that the ADA only tells places to have wheelchair ramps and lowered water fountains. When a parent comes in and makes a request under the ADA to have the camp provide a low-cost or no-cost accommodation such as having their staff watch some YouTube videos about accommodating the disability and providing large-print materials, this may be the first time the camp director has had anyone make this type of request, and the camp director may in good faith tell the parent that that sort of thing is provided by parents. If the camp director follows disability organizations on social media and is seeing them post content about parents modifying the materials for summer camp with no mention that the camp is obligated to do this...ugh. 

So again, in this situation I wouldn't begrudge the parent who makes the materials and sends their own aide for a weeklong day camp on their child's favorite topic rather than not attending or attending but being excluded. As much as I know that people often end up providing their own accommodations, I do absolutely encourage parents to initially send in ADA letters stating what is needed and reminding the organization of their obligations, and to model this human right for their children. I encourage families to push this to whatever extent is safe for their family -- especially when dealing with a well-funded organization with a high degree of community exposure -- by doing things such as contacting their regional ADA Technical Assistance organization and forwarding the e-mails clarifying what the organization's obligations are.

If you see these posts, please do some advocacy by leaving them a polite comment that they need to remind parents that summer camps, sports teams, music schools, YMCAs, etc. (basically everywhere except for religious organizations performing religious functions) are covered under Title III of the ADA, and they should be providing these accommodations. 

New sections of LGBTQ youth groups have opened -- no waitlist!

Alt: heavily edited photo of rainbow umbrellas and banners at a pride parade

weekly Zoom groups for LGBTQ youth 8-18 

open to folks located anywhere in the world

$10 per week

not insurance eligible/not a therapeutic group

erika @ erikashira . com if interested

This is not a therapy group, so it is open to folks located anywhere. Group members tend to be mostly neurodivergent, a mix of about 2/3 homeschoolers and 1/3 not. We mostly free chat about whatever the group wants, whether that's queer topics, personal updates, hobbies, current events, or really anything else. As these are not therapy groups, members and facilitator can provide general support and suggestions for dealing with queer-related exploration, learning issues, mental health issues, and so forth, but I cannot provide tailored medical advice as I might in a therapy group. Members often bring photos/videos/etc. to share as well, whether their own creations or just things they enjoyed and thought others might like. When people are interested, we sometimes play games (always free-to-play online games that do not require any particular hardware or software, like Garticphone or Jackbox). 

We are completely flexible regarding participation with camera/mic on or off, chat box only, or switching it up depending on comfort level. For safety, I do need members to initially verify on camera that they are the same person each time and appear to be roughly in the correct age range. As members tend to be neurodivergent, I try to provide predictability and clear feedback. Particularly if we are playing a game or doing an activity, I let people know clearly for instance whether I expect hand-raising. During interactions, I promote universal social skills -- boundaries, consent, perspective-taking, inclusion, clear communication, self-advocacy, manners, etc. -- but I do not believe in promoting neurotypical communication styles or white/Anglo communication styles over other equally valid communication styles. Youth and parents are very much welcome to let me know if youth have particular types of accommodations or preferred feedback styles that are helpful. 

10/19/25: These groups typically have a long waitlist, but I opened two new sections to clean up the waitlist and accommodate people wanting to move to other times, so there is availability. 

Groups with current open slots:

• Wednesday 5pm Eastern U.S. time ages 13-18
• Thursday 6pm Eastern U.S. time ages 13-18
• Thursday 7pm Eastern U.S. time ages 8-12
• Sunday 4pm Eastern U.S. time ages 13-18

Folks are also welcome to join the waitlist for any other slots. erika @ erikashira . com

We also run LGBTQ Dungeons and Dragons campaigns and LGBTQ book groups with a similar flavor, but with a specific focus -- e-mail for more info. 

LGBTQ Dungeons and Dragons groups running for ages 8-12 and 13-17

Image: roleplaying dice and stones reading "magic" and "strength," lying on a six-color pride flag

• Groups meet weekly on Zoom for 90 minutes, for six weeks. 
• Group is led by a clinician/educator along with a previously identified teen or young adult Dungeon Master. 
• Groups are open to anyone, anywhere in the world, as they are not therapy groups. Insurance cannot be billed for these groups.
• Any youth who identify as comfortable in LGBTQ space or wanting to explore LGBTQ space are welcome. Game play is LGBTQ affirming and youth tend to play as out queer characters. Youth will not typically be in the position of needing to discuss their personal identities except as they choose to. 
• Our social environment is neurodiversity affirming, learners tend to be neurodivergent, and we aim to be open and responsive to any stated or apparent needs. Communicating through text chat, voice, or a combo are all great.
• Players should have basic familiarity with the game, such as watching others play or via YouTube. We are low-key and friendly and happy to help out players who don't have all of the rules of gameplay memorized. Beginners are very much welcome!
• Group is $10 per week, charged weekly. Sliding scale is available for those with financial need.

Ages 8-12 meets 6:30-8:00 Mondays Eastern U.S. time, starting September 29th.

Ages 13-17 meets 6:00-7:30 Sundays Eastern U.S. time, starting September 28th.

E-mail erika@erikashira.com for signup link. 

Grow Therapy recruiters don't read profiles and don't respect boundaries

Emma Beachy of Grow Therapy has sent me multiple e-mails to the contact info harvested off of LinkedIn (I am using different e-mail addresses for LinkedIn, insurance credentialing, NPI/CAQH, etc. so as to enable me to track such things).

My LinkedIn profile states I do not provide therapy and am not interested in hearing from recruiters. These recruiters are just harvesting profiles that contain certain credentials and are not reading the profiles at all. At least this one doesn't say they read my profile and are sure I would be perfect for their practice! 

I probably wouldn't have posted this one, since it's minimally obnoxious as far as recruiter spamming goes and I get that people gotta make the money and pay the bills, except this person also located a phone number for my practice, which is a bit of a chore to track down. I discovered today that several weeks ago they left a voice message on a mailbox that clearly states it is an information-only line, messages will not be returned, and directs people how to reach me via my website. The service I use unfortunately does not have an option for a true outgoing-only message, so I periodically discover people have left messages that do not acknowledge the outgoing message whatsoever and just say to call them back.

If you are any type of mental health business, you really should be doing better at respecting people's stated boundaries. Also, do you know how many clients I have who absolutely cannot do voice calls due to hearing or other disabilities, who have this stated on their voicemail along with how to text or e-mail them, and who also have people leave messages that just say they need to call back? And how many of the people who do this are healthcare providers? We gotta do better.

(BTW, I do have a line with monitored voicemail that I can give out to the very infrequent client or caregiver who does best with voice calls. But I overwhelmingly find that: 1. People of all ages and disabilities prefer texting/e-mailing for scheduling and reminders and 2. Large healthcare providers in particular seem to be stuck on voice calls as the only way to reach people, which is ironic, since they also are seeing people all day and wouldn't be able to pick up a call.)

 

Screenshot of e-mail from emma.beachy@growtherapy.com, which says: Hey Erika​, Providers we work with share that gaining new clients is their biggest headache when growing their private practice. In Massachusetts alone, providers averaged 7 new intakes from our marketing efforts last month! But growth isn’t just about referrals— it’s about ensuring clients have the coverage to access care consistently. I’d love to share more about Grow’s mission and how we’re helping increase access to mental health services! Would you be open to a quick call? Feel free to find time on my calendar

New free Zoom group for LGBTQ young adults 18-24

I am posting to promote this specific group as it currently has no waitlist.

I also still have several low-cost/sliding scale groups for LGBTQ youth 6-18, though these tend to have waitlists, but please do e-mail me if interested. 

weekly Zoom group for LGBTQ young adults 

ages 18-24

open to folks located anywhere

completely free of charge always

Thursdays 5pm Eastern U.S. time

erika @ erikashira . com if interested
or reserve on Eventbrite below

This is not a therapy group, so it is open to folks located anywhere. Group members tend to be neurodivergent, a lot of former homeschoolers or people who otherwise didn't really click with school. We mostly free chat about whatever the group wants, whether that's queer topics, personal updates, hobbies, current events, questions about adulting, or really anything else. Members can bring photos/videos/etc. to share as well, whether their own creations or just things they enjoyed and thought others might like. When people are interested, we sometimes play games (always free-to-play online games that don't require any particular hardware or software, like Garticphone or Jackbox). 

We are completely flexible as to participation with camera/mic on or off, chat box only, or switching it up depending on comfort level.

Interested folks can e-mail or also reserve a free ticket via Eventbrite by clicking here. It looks like unfortunately each week does have to be reserved separately.

Now taking private insurance for short-term evaluation and consultation for children, adults, and families

I am now taking most Massachusetts private insurance in order to provide more people with affordable access to care. I am unfortunately having a difficult time taking MassHealth as a solo clinician, but I will keep trying. 

More about types of services I provide and my general philosophies can be found here.

I am particularly prioritizing brief short-term work with individuals and families who are finding themselves on someone's radar and needing to connect with services quickly in order to receive an initial evaluation and recommendations for pursuing further services (or assurance that nothing formal is needed at this time). I can provide brief developmental and psychological assessment of infants and children of all ages with and without disabilities, brief diagnostic and clinical assessment for adults with and without disabilities, and other related types of brief assessment and recommendations. I also specialize in working with adults, particularly parents, who may have undiagnosed neurodivergence and may be facing misdiagnosis or misconceptions as to the reasons they present as "a bit different" and are in need of an affirming evaluation. My evaluations are disability-positive, neurodiversity-affirming, and respectful of family culture including subcultural affinities. 

I also offer flexible consultation models for children and adults with disabilities who have no pressing clinical concerns, but find themselves needing an established connection with a clinician for verification of disability status or other systems-related reasons. I believe that most people who have had psychiatric or neurodevelopmental disabilities all of their lives do not need treatment, but I also understand that the medical model believes that disabled folks "are followed by someone for that" and I am happy to be that someone. 

Similarly, I offer flexible consultation/training models for children for whom frequent talk therapy is not the best model due to trauma, neurodivergence, culture, or some combination, and who may do better with a model in which the clinician teaches the family and familiar providers to support the youth more indirectly. 

I understand that when working with systems, time is often of the essence in terms of establishing an initial connection with a provider and having someone on record. I make it a point to see folks for an initial appointment usually within the week, though subsequent meetings, collateral contacts if appropriate, and written evaluations unfortunately always take some time. My main goal is to prevent families from being referred to crisis services in the absence of an actual emergency and/or reported to DCF "to make sure services are in place" absent concerns of actual abuse or neglect, as these types of contacts are traumatic and an unnecessary use of services that should be reserved for emergencies. 

photo I took of a red maple leaf on rocky pavement

Accepting most Massachusetts private insurance for gender-affirming care letters

More info here.

I am currently accepting Aetna, Cigna, Carelon, and soon will be accepting most of the other private insurance plans, except for BCBS unfortunately.

I will typically write a gender-affirming care letter in 1-2 sessions. I believe in personal autonomy and client-directed care. I may require documentation or collateral consults in a few instances, but there is very little about someone's presentation or history that I would consider a barrier to a grown adult pursuing care that has been shown to improve quality of life and stability in almost all instances. I am very familiar with the diverse presentation of autistic and other neurodivergent adults and make it a point to be sensitive and educate myself about clients' ethnicities, religions, and other cultural aspects when performing assessments. 

Naming and shaming: Mental health companies using obnoxious spammy recruiters

Like an increasing number of us, I have added to my LinkedIn profile that I do not wish to hear from recruiters. For years, I have had in my "about" section that I do not provide ongoing therapy and do not wish to hear from recruiters regarding therapy jobs. I do also of course explain what types of services I do provide, and that I am happy to discuss sliding scales and creative solutions for those who, you know, actually have some idea what I do and are looking for something in that ballpark.

The recruiters don't actually read the profiles though, despite sending messages stating they are extremely impressed with my profile and thought I would be a good fit. 

Since the "about" section text wasn't working to get them to stop, I moved my message to recruiters to the headline: 

Image: My LinkedIn profile, showing a white middle-aged person with pink hair. Text reads Erika Shira (Ask me my pronouns) LMHC, MT-BC. Not interested in hearing from recruiters about services I do not provide. Messages from individuals or businesses who ignore boundaries will be reposted publicly.

They kept messaging, so I added "messages from individuals or businesses who ignore boundaries will be reposted publicly" and now will be doing so. I certainly would not want to seek mental health care nor employment with a company that doesn't know how to treat humans like humans, so I will be calling them out when I see them. Honestly, doesn't it seem like basic human decency to browse someone's social media or public online presence a little bit before contacting them? I make it a habit to always do this when messaging people with whom I do not have regular contact; more than once, I have seen that someone I was considering messaging has posted about a loss in the family or something similar that is occupying their mind. I've been grateful to see this so I knew not to message them some annoying question, but rather to send them a message of support if we have that sort of relationship and to leave them in peace if we do not. Some of these recruiters apparently don't even read people's headlines before spamming them, and may be using bots.

Here's one I got recently:

LinkedIn message from Ali Turin, asking me to apply for a job at Charlie Health

Ali Turin, a Senior Clinical Talent Acquisition Specialist at Charlie Health, messaged me with a job listing. The message reads, in part, "Our Creative Arts Programming Leadership flagged your profile as a great fit for Charlie Health..." 

How? They saw the headline that says I don't provide therapy and don't wish to hear from recruiters, yet thought they'd try anyway? Interesting. 

LinkedIn message with my response, which is in the text below

I replied, stating "Is there a reason you are ignoring where my profile clearly states I do not provide therapy and not to contact me with such offers?" I did not receive any reply.

I did, however, receive not one but two e-mails from Ali Turin of Charlie Health, apparently just wanting to make sure I was not interested in working for such a ridiculous organization:

E-mail from Ali Turin, which I detail below

The e-mail reads, "Hey Erika, I hope you're well! I just shot you a note on LinkedIn but also wanted to follow up via email in case you don't check your LinkedIn often," then proceeds to discuss the job listing and has a Calendly link to schedule a 30-minute chat in case I just hadn't gotten enough of Ali Turin.

Another e-mail from Ali Turin and my response, which I detail below

This e-mail reads "Hey Erika, Wanted to quickly double down on my last note, in case it slipped through the cracks. I'm excited to share more about how we have built a world-class clinical team and model. It would also be great to learn more about you (your online profile can only tell me so much!). Are you up for a call?"

My response reads, "Hi, I responded to you on LinkedIn. I don't appreciate the spamming and ignoring of boundaries, though it does let me know something about your company's values in case anyone asks."

So yeah, if anyone is interested in knowing more about Charlie Health, there you go. 

If you are administering screening tools to everyone, this is poor clinical practice

When using screening tools, make sure you are actually at the point where this is necessary/appropriate.

What is a screening tool? It's exactly that. It's something that's meant to be administered to broad populations in order to flag undetected conditions that might otherwise go unnoticed, so these can be addressed. The tool is administered, and if it is positive for certain things, it then creates a record that the person has a previously undetected/currently unmet need.

If you are in a setting that uses these, make sure you understand this, and only administer screening tools to people who need to be screened, i.e., people who don't know if they have any conditions for which the tool screens. 

If you are doing hearing screenings, don't administer these to people with known hearing loss. Ask everyone if they've been previously identified, because medical/school records are often inaccurate (no need to ask someone who you do know is Deaf/hard of hearing). Just document that it was deferred due to already being identified. If you administer a screener, this create a records at the individual and population level showing they have a previously undetected/currently unmet need, which they don't. It skews data on how many people are going around with undetected conditions, and it enters into the person's individual medical or school record that they are experiencing medical neglect that they are actually not.

If you are doing screenings to detect emotional/behavioral concerns in children, don't administer these to youth/families who report their child has a diagnosed psychiatric disability for which they are receiving treatment. It still may be appropriate to administer other brief tools that look at social functioning, mood, etc. over time, but not the tools that are intended to flag undetected concerns.

Also, with the tools that are based on self-report, most are unclear whether the person is to answer them based on how they function with their accommodations (medication, learned strategies, loved ones who are aware and support appropriately, accommodations in place at work or school) or how they would function without these. If we fill them out based on current functioning, we create a medical record showing that a person with an ongoing disability has no functional impairment. This creates problems. If we fill them out based on how the person would function with no intervention, we create a medical record that someone is functioning poorly and has unmet needs. This also creates problems.

If you work somewhere that has no way to indicate that you deferred a screening for a valid clinical reason, or which returns metrics that the provider or facility are out of compliance for not administering a tool, this is not patient-centered and is poor practice. Aside from the clinical reasons I discussed, any person should be able to decline any procedure without any context of pressure or resentment around this. Aside from rare true imminent risk situations, health care and social services participation should be no different from going to the hairdresser or auto mechanic in terms of how the professional explains the pros and cons of something, the customer decides what they would like, and that's the end of it. Insurance sometimes complicates this, but dealing with the insurance companies is something we as providers have chosen to take on, and should not be passing on to the patient.