1st Edition

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

By Amy Marschall Copyright 2024
    210 Pages 1 B/W Illustrations
    by Routledge

    210 Pages 1 B/W Illustrations
    by Routledge

    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.

    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


    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.

    "Dr. Marschall's book would have saved me so much time and stress when I was a new therapist trying to figure out billing insurance companies and clinical documentation! This guide should be on the shelf of all mental health counseling students and new mental health professionals alike. I found the sample intake interviews and notes to be very helpful!"

    Casey O'Brien Martin, LMHC, REAT, RN, Author of Skills for Big Feelings: A Guide for Teaching Kids Relaxation, Regulation, and Coping Techniques  

    "Regardless of population, documentation in the clinical world can be a challenging process to navigate. Clinical Documentation with Children and Adolescents by Dr. Amy Marschall, Psy.D., provides an articulate and comprehensive guide for the nuances in practice that must be approached specifically for child and adolescent clients. With thoughtful consideration of each step in the documentation process and excellent detailed templates and examples, this is a phenomenal resource for seasoned mental health professionals and is sure to become an essential addition to the library of any clinical student or new clinician who is interested in working with this population."

    Andrea Dorn, MSW, LISW-CP, Founder of Bloom Therapy and Wellness and Author of the Mindful Steps Series™

    "Clinical Documentation for Children and Adolescents is a must-read for any clinician working with this population. Dr. Marschall provides nuanced and detailed information to help any provider navigate the complexity of potential ethical and legal issues. This versatile manuscript will serve as a timeless guide for students as well as the most-seasoned clinicians."

    Dr. Marina Harris, PhD, Psychologist, CEO of Bloom Psychology Group