Clinical Documentation with Children and Adolescents

This book addresses the unique challenges therapists face when documenting their clinical work with children, providing insight into what ethical, appropriate, and culturally competent practice looks like. Clinical documentation is vital for ethical and legal practice, and good documentation helps clinicians leave room for client-centered and age-appropriate interventions, such as play therapy. Beginning with an overview of the important considerations unique to providers working with children, Amy Marschall offers guidance on all aspects of clinical documentation, such as intakes, treatment plans, mental status examinations, progress notes, safety plans, and more. Each chapter includes specific examples of clinical situations with guidance on how to document these situations effectively. With chapters on client confidentiality and telehealth, as well as special attention being paid to cultural awareness, including race, ethnicity, gender, sexual orientation, and socioeconomic status, this book includes blank templates of treatment plans, progress notes, and risk assessments for therapists to use in their practice. This book is essential for any mental health professional who works with children in both individual and family work, including psychologists, licensed clinical social workers, licensed professional counselors, mental health counselors, marriage and family therapists, play therapists, school counselors, and therapist interns.

Amy Marschall, PsyD, is a licensed psychologist, speaker, and author, who lives in Sioux Falls, South Dakota, with her husband and two cats. Dr. Marschall specializes in child and adolescent mental healthcare and provides therapy and assessment through her private practice, RMH Therapy.

1. Overview of Clinical Documentation for Children and Adolescents  2. Informed Consent and Other Paperwork  3. Billing and Insurance  4. Intakes and Diagnostic Interviews  5. Diagnoses  6. Treatment Plans  7. Mental Status Examinations  8. Progress Notes  9. Consultations and Contact Notes  10. Risk Assessments and Safety Plans  11. Letters