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Clinical Documentation with Children and Adolescents: Treatment, Risks, and Ethics

Enroll in the Online Self-Study and complete the training on your own schedule.
3 Ethics CE hours available for behavioral health clinicians completing the Online Self-Study.

Clinical documentation is complex and comes with a huge range of seemingly never-ending requirements. You must note every interaction, appointment, and follow-up, including clinical justification for your chosen interventions, mental status, safety concerns, progress toward treatment goals, and much more. Providers must be knowledgeable in the legal, ethical, and payer requirements for documentation.

These considerations become even more complex when working with clients below the age of majority. Clients have a legal right to view their medical records, but this means that parents and guardians have the right to request their children’s records. Mandated reporting, custody battles, and family therapy all impact your ability to keep your records private. School staff who are not HIPAA-trained or bound by the same confidentiality laws as providers may also access client records in some circumstances. How do you document when a client discloses something that needs to be kept confidential? How do you get assent for treatment and release with someone under the age of majority?

This program is for counselors, social workers, family therapists, play therapists, psychologists, school counselors, and any other mental health professional who work with minor clients. It is an intermediate to advanced course for individuals who are already competent to provide mental health services to children and teens but who struggle with ethical and legal clinical documentation. It bridges gaps in knowledge about best practice for protecting our clients, offering the best possible care, and meeting all requirements for documentation.

By completing this course, you will gain an understanding of special considerations around privacy, safety, and medical necessity, ensuring that your documentation meets payer requirements, applicable laws, and your ethics code. When you finish this course, you will be ready to complete intake notes, diagnostic conceptualizations, treatment plans, progress notes, safety plans, and more with child and adolescent clients.

Select each tab above to view specific details about this course

Clinical documentation is complex and comes with a huge range of seemingly never-ending requirements. You must note every interaction, appointment, and follow-up, including clinical justification for your chosen interventions, mental status, safety concerns, progress toward treatment goals, and much more. Providers must be knowledgeable in the legal, ethical, and payer requirements for documentation.

These considerations become even more complex when working with clients below the age of majority. Clients have a legal right to view their medical records, but this means that parents and guardians have the right to request their children’s records. Mandated reporting, custody battles, and family therapy all impact your ability to keep your records private. School staff who are not HIPAA-trained or bound by the same confidentiality laws as providers may also access client records in some circumstances. How do you document when a client discloses something that needs to be kept confidential? How do you get assent for treatment and release with someone under the age of majority?

This program is for counselors, social workers, family therapists, play therapists, psychologists, school counselors, and any other mental health professional who work with minor clients. It is an intermediate to advanced course for individuals who are already competent to provide mental health services to children and teens but who struggle with ethical and legal clinical documentation. It bridges gaps in knowledge about best practice for protecting our clients, offering the best possible care, and meeting all requirements for documentation.

By completing this course, you will gain an understanding of special considerations around privacy, safety, and medical necessity, ensuring that your documentation meets payer requirements, applicable laws, and your ethics code. When you finish this course, you will be ready to complete intake notes, diagnostic conceptualizations, treatment plans, progress notes, safety plans, and more with child and adolescent clients.

This course was recorded February 2, 2024.

Upon completion of this training, professionals will be able to do the following:

  • Design treatment plans and documentation of clinical interventions for minor clients that maintain legal and ethical standards.
  • Assess concerns of confidentiality and privacy for children and teen clients, and construct office policies that uphold these ethical ideals while maintaining documentation standards.
  • Accurately diagnose child and adolescent clients based on age and developmental level, with appropriate justification and documentation of symptoms.

Dr. Amy Marschall, Psy.D

Dr. Marschall earned her doctoral degree in clinical psychology from the University of Hartford in West Hartford, Connecticut. She completed her pre-doctoral internship through the National Psychology Training Consortium and her post-doctoral residency at Family Psychological Center, PA.

Dr. Marschall has been in practice since 2016 and currently owns a private practice, RMH-Therapy, where she provides therapy primarily to children and adolescents and psychological evaluations. Her clinical specializations include trauma-informed and neurodiversity-affirming care, trauma therapy, autism, and ADHD.

She also provides ADHD assessments through ADHD Online and therapy services through Spring Health. She teaches continuing education through PESI, Spring Health, and the Telehealth Certification Institute.

Dr. Marschall is certified in telemental health and is the author of Telemental Health with Kids Toolbox and Telemental Health with Kids Toolbox: Volume 2.

She is also the author of the following: 

  • I Don’t Want To Be Bad: A CBT Workbook for Kids, Parents, and the Professionals who Help Them
  • Clinical Documentation with Children and Adolescents
  • A Year of Resiliency: 465 Journal Prompts to Become Your Strongest Self
  • Armani Doesn’t Feel Well: A Book to Help Sick Kids

She created a website, Resiliency Mental Health, to provide resources for therapists and anyone who wants to learn more about mental health.

Credit Hours: CEs provided with this course include 3 ethics continuing education hours of credit.

Counselors: Telehealth Certification Institute LLC has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6693. Programs that do not qualify for NBCC credit are clearly identified. Telehealth Certification Institute LLC is solely responsible for all aspects of the programs.

Telehealth Certification Institute LLC is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for Licensed Mental Health Counselors #MHC-0048.

Marriage and Family Therapists: Many MFT licensing boards accept our courses or one of the approvals which we have from professional associations. You can check with your board to determine if this course would be accepted by your licensing board.

Social Workers: Telehealth Certification Institute LLC #1609, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 05/02/2021 – 05/02/2024. Social workers completing this course receive 3 ethics continuing education credits.

Telehealth Certification Institute LLC is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for Licensed Social Workers #SW-0435.

Addiction Professionals: This course has been approved by Telehealth Certification Institute LLC, as a NAADAC Approved Education Provider, for educational credits. NAADAC Provider #193104, Telehealth Certification Institute LLC is responsible for all aspects of the programing.

Psychologists: Telehealth Certification Institute LLC is approved by the American Psychological Association to sponsor continuing education for psychologists. Telehealth Certification Institute LLC maintains responsibility for this program and its content.

Telehealth Certification Institute LLC is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for Licensed Psychologists #PSY-0128.

Art Therapists: Telehealth Certification Institute LLC is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for Licensed Creative Arts Therapists #CAT-0093.

Other Professionals: This activity qualifies for 180 minutes of instructional content as required by many national, state and local licensing boards and professional organizations.  Retain your certificate of completion and contact your board or organization for specific filing requirements.

This is a non-interactive, self-study course.

To receive your certificate of completion you must complete the course in its entirety.

Online courses are completed by registering, logging in, navigating to your course using the menu (My Courses – the Course Title), completing all of the modules, completing and passing the post-test, and completing the course evaluation. Participants have 6 months from registration to access and complete online self-study courses.

Live Webinar courses are completed by registering, logging in to this website, navigating to your course using the menu (My Courses – the Course Title), attending the full course via webinar, submitting your attendance, and completing the post-test and course evaluation online.

Psychologists and other professionals seeking CE credit through our approval with the American Psychological Association are asked, but not required, to complete the course evaluation before obtaining their certificate of completion, however passing a post-test for online self-study courses and live webinars, and submitting one's attendance for live on-site and live webinars is required.

You can receive your certificate of completion by logging onto this website, navigating to the course using the menu (My Courses – the Course Title), scroll to the bottom of your course, and click on your certificate to either download it or print it.

Directions for completing a course can be found by clicking here.

Accommodations for Individuals with Disabilities

Click here to view our Accommodations for Individuals with Disabilities.

Cancellation Policy

Refunds are offered within the first 30 days for courses which have not been completed.  There is a 10% service fee for refunds.

Grievance Policy

Click here to view our Grievance Policy.

This course is intended for clinicians who provide behavioral health services.

Teaching methods for this course include recorded lectures, videos, a post-test, and a course evaluation.


This program was recorded February 2, 2024

You have six months to access online courses from the time of purchase.

Dr. Amy Marschal headshot

Amy Marschall
Psy.D.

Dr. Marschall earned her doctoral degree in clinical psychology from the University of Hartford in West Hartford, Connecticut. She completed her pre-doctoral internship through the National Psychology Training Consortium and her post-doctoral residency at Family Psychological Center, PA.

Dr. Marschall has been in practice since 2016 and currently owns a private practice, RMH-Therapy, where she provides therapy primarily to children and adolescents and psychological evaluations. Her clinical specializations include trauma-informed and neurodiversity-affirming care, trauma therapy, autism, and ADHD.

She also provides ADHD assessments through ADHD Online and therapy services through Spring Health. She teaches continuing education through PESI, Spring Health, and the Telehealth Certification Institute.

Dr. Marschall is certified in telemental health and is the author of Telemental Health with Kids Toolbox and Telemental Health with Kids Toolbox: Volume 2.

She is also the author of the following: 

  • I Don’t Want To Be Bad: A CBT Workbook for Kids, Parents, and the Professionals who Help Them
  • Clinical Documentation with Children and Adolescents
  • A Year of Resiliency: 465 Journal Prompts to Become Your Strongest Self
  • Armani Doesn’t Feel Well: A Book to Help Sick Kids

She created a website, Resiliency Mental Health, to provide resources for therapists and anyone who wants to learn more about mental health.