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

Join us for a Live Webinar on February 2, 2024 from 12-3:20pm EST
3 Ethics CE hours available for behavioral health clinicians

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.

 Learning Objectives:

  • 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.
CE Hours
How to Attend the Webinar
Recording of Event

This webinar is also offered without CEs for free.

Clinical Documentation with Children and Adolescents: Treatment, Risks, and Ethics Webinar
Dr. Amy Marschal headshot

Amy Marschall

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.