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 is a non-interactive, self-study course that offers over 3 hours of recorded video instruction, a post-test and a course evaluation.
From the time of registration, you have six months to access the coursework.
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: This course consists of 3 ethics non-contact hours.
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. Approval renewal date: 1/31/2026
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 to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Telehealth Certification Institute LLC maintains responsibility for this course. 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. Approval renewal date: 2/28/2026
Addiction Professionals: Telehealth Certification Institute is an approved provider of continuing education by NAADAC, The Association for Addiction Professionals, provider #193104. Full attendance is required; no partial credit will be awarded for partial attendance.
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. Effective 8/31/2021 – 8/31/2024
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. 7/21/2021 – 7/31/2024
Other Professionals: This activity qualifies for 360 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.
To complete an Online Self Study Course, one must register, log in, select the My Courses option from the menu items, click the Course Title, complete all of the modules, complete and pass the post-test(s), and complete the course evaluation.
A grade of at least 80% or more is required to pass the post-test. Retaking the post-test is possible until the participant is able to pass the test.
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 submitting one's attendance for live on-site and live webinars is required.
You can download or print your certificate of completion by logging into your account, navigating to the course by selecting the My Courses option from the menu items, clicking the Course Title, scrolling to the Certificate of Completion section, and clicking on the Certificate of Completion link to either download it or print it.
Participants may request a printed version of their certificate of completion to be delivered by mail. A shipping/handling fee of $6.95 will be charged per request. Shipping internationally may require an additional charge.
Directions for completing a course can be found by clicking here.
This course is intended for clinicians who provide behavioral health services.
This is a non-interactive, self-study course. Teaching methods for this course include recorded lectures, videos, a post-test, and a course evaluation.
This course was recorded 2/2/24