In the case of Illinois Nurses Association v. Rosenblatt et al. (2025), hospital-based nurses were providing health care to clients both prior to and after admissions. Nurses expressed concerns that they could be violating state licensing laws because the hospital had instructed them not to ask patients for their physical locations; thus, the nurses could not determine whether they were serving clients who were in Illinois or out of state.
In its decision, the court noted:
“Providing care to out-of-state patients is unlawful in many states, but nurses are reluctant to withhold care given the potentially dire consequences for patients… A nurse that refuses an out-of-state telehealth assignment may be subject to discipline under both Hospital policy and the nurse‘s state licensing agency.”
Relevance to Mental Health Professionals
The case cited above was a trial court decision in Illinois and applied specifically to the nursing profession. Technically, the decision, therefore, is not a binding decision for courts in other states or for other professions, whose regulatory laws may be somewhat different than the laws for nurses. Still, the rationale for the court’s decision seems relevant to mental health professionals (MHPs). Just as regulatory laws for nurses typically state that nurses may provide nursing services only in states where they are licensed, laws regulating licensed MHPs also restrict practice to where they are licensed.
From a legal perspective, the location where practice takes place is defined primarily by where the client is physically located (Center for Connected Health Policy, n.d.). So, whether MHPs are providing therapy via telephone, videoconference, interactive online applications, or text messaging, they should ask where the client is located. If the client is located in another state where the MHP is not licensed, the MHP could be violating state laws. Ignorance of where the client is located may not be an excuse, at least from a legal perspective. Avoiding inquiry about client location does not shield MHPs from potential violations.
Ethical-Legal Tensions
MHPs have ethical duties to ensure clients have access to needed services (ACA, 2014; APA, 2017; NASW, 2021). The principle of fidelity suggests that MHPs should prioritize serving their clients and their well-being (Barsky, 2023). Consider a client in need of services, but who is out-of-state when services need to be provided. One response would be to refer the client to another MHP in the state where the client is currently located. Still, it may be in the client’s best interests to have continuity of care, which could mean that the original MHP should provide services even though the client is not in a state where the MHP is licensed. Just as the nurses in the Illinois case faced a conflict between their patient’s best interests and state laws, so may MHPs.
When such tensions arise, MHPs should strive to address the conflict in a manner that satisfies both. Since there may be no easy answer, consulting with attorneys, ethicists, risk managers, or clinical consultants may be prudent. Potential strategies include:
Obtaining licensure in all states where clients are likely to be located (e.g., an MHP in Kansas City, Missouri may want to be licensed in the state of Kansas because it is so close to the MHP’s primary location).
During the informed consent process, letting clients know that the MHP can only provide services in the state or states where licensed to practice.
Exercising due diligence by verifying client location at the beginning of telehealth sessions.
Offering referrals to alternative service providers when clients require services in states where the MHP lacks licensure.
The Question of What Constitutes Practice
Licensing laws prohibit practice in states where MHPs are not currently licensed (Center for Connected Health Policy, n.d.). However, there may be questions about “what constitutes practice.” Not all communications with clients outside the state are necessarily considered practice. For instance, administrative communications such as scheduling appointments with out-of-state clients are unlikely to constitute practice. Similarly, brief follow-up calls with clients to see how they are doing may fall outside regulatory definitions. But what if the follow-up call generates new concerns and the client needs or requests assistance during the call? What if an MHP assigns clients online homework between sessions and the client completes and submits it from another state? Does this situation constitute out-of-state practice?
While some situations may be relatively clear, there may be fuzzy lines about whether certain types of tech-assisted interactions between MHPs and clients constitute practice for regulatory purposes. “Provider beware”: For MHPs with questions about whether particular types of telephone, videoconference, or text-messaging interactions constitute practice, it may be wise to seek advice from an attorney, professional association, or licensing body. Some states and some professions may have already issued clarifications about what constitutes practice in terms of distance or virtual interactions with clients. Others may still need to do so.