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

Description

Clinical documentation for minors isn’t just a task—it’s a delicate and high-stakes balancing act that impacts a young client’s safety, autonomy, trust, and care outcomes. Documenting ethically, legally, and compassionately can make or break a therapeutic relationship, especially when guardians, systems, and developmental differences are involved.

Clinicians working with children and adolescents need more than templates and checklists—they need clear guidance that respects the complexities of family systems, confidentiality laws, billing, and consent. This course empowers you to approach documentation with clarity, competence, and confidence.

Dr. Amy Marschall, Psy.D., is a licensed psychologist who has built her career on trauma-informed, developmentally appropriate, and neurodiversity-affirming care for children and adolescents. As the author of Clinical Documentation with Children and Adolescents and a seasoned educator and clinician, Dr. Marschall translates legal standards and ethical principles into accessible, real-world practices clinicians can use immediately.

With both compassion and precision, Dr. Marschall walks you through the intricacies of documenting treatment for minors—from intake through discharge—while helping you avoid common legal pitfalls. Her approach is realistic, inclusive, and grounded in years of direct clinical work, consultation, and training.

Topics include age-appropriate diagnostic documentation, SMART and PACT goal-setting in treatment plans, billing codes, SOAP and BIRP note structures, mental status exams, documentation related to consent and custody agreements, best practices for guardian communication, risk assessment and safety planning, letters for accommodations or court, and protecting confidentiality in a digitized healthcare system.

Key Takeaways:

• Write with confidence and clarity: Learn how to document clinical interventions, assessments, and treatment plans for minor clients in ways that meet ethical and legal standards.

• Navigate confidentiality complexities: Get clear on what to include—and exclude—from documentation when working with children, adolescents, and their families.

• Diagnose responsibly: Understand how to document accurate, developmentally appropriate diagnoses that are defensible and clinically meaningful.

Why This Course?

• Specialized focus on minors: Unlike general documentation courses, this training is tailored specifically to the unique legal, ethical, and developmental complexities of working with young clients.

• Led by a seasoned expert: Dr. Marschall is not only a specialist in child and adolescent therapy but also the author of the go-to book on this very topic.

• Practical, real-world guidance: Expect tools, examples, and case-informed strategies—not just theory—that you can implement right away.

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.

Whether you're in private practice, school settings, telehealth, or agency work, this course offers the clarity and support you need to ensure your documentation protects your clients—and yourself. Step into this training and leave with tools that elevate both your practice and peace of mind.

Add this course to your cart to begin learning instantly.

Format and Access

This is a non-interactive, self-study course that offers over 3 hours of recorded video instruction, a post-test and a course evaluation.

Course Details

Availability: 

From the time of registration, you have six months to access the coursework.

Who Should Attend: 

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

Teaching Methods: 

This is a non-interactive, self-study course. Teaching methods for this course include recorded lectures, videos, a post-test, and a course evaluation.

How to Attend: 

Course access and completion instructions.

Instructor and Disclosures

Instructor

About 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.

Disclosure Statement: 

The instructor(s) for this course receive compensation for their services. There are no reported conflicts of interest to disclose.

CE Hours

Credit Hours:

This course consists of 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 your licensing board would accept this course.

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 marriage and family therapists #MFT-0135, effective May 8, 2025.

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: 05/02/2024 – 05/02/2027. 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, effective 2/20/2024. NAADAC Provider #193104, Telehealth Certification Institute LLC is responsible for all aspects of the programming.

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 course 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.

Accommodations and Policies

Close Captioning is available for live webinars and recorded video presentations.

You can click on the following links to view our policies:

• Accommodations for Individuals with Disabilities.
• Cancellation Policy
• Grievance Policy
• Support Options
• Disclosure Statement