Adolescent Confidential Visit Note (HEADSSS)

Date: [Date]

Patient: [Patient name or initials]

DOB: [DOB]

Provider: [Provider name and credentials]

Confidentiality and Consent

• Participants by visit segment:
  • Initial portion: [Caregiver(s) present / patient only / other]
  • Adolescent private interview: [Yes—patient seen alone / No—reason documented below]
  • Chaperone for exam: [present / offered and declined / not applicable] (Only include if exam was performed or offered)
• If not seen alone: [Reason adolescent was not interviewed privately and privacy-adapted approach used] (Only include if private interview did not occur)
• Confidentiality discussion: [Confidentiality and limits reviewed, including safety concerns, mandatory reporting, and EHR/portal visibility]
• Preferred confidential contact method: [Phone / text / patient portal / other] — Safe to use: [yes / no / uncertain]

Reason for Visit

Patient priorities: [Patient-stated reason in 1–2 sentences] (Use patient voice; avoid confidential details caregiver did not hear)

Caregiver concerns: [Caregiver priorities in 1–2 sentences, if present] (Omit if caregiver not present)

HEADSSS Psychosocial History

(Proceed from less sensitive to more sensitive topics. Begin with strengths. Use "Patient reports…" language. For positive findings, note key facts, risk indicators, and counseling provided. Document screening tool names and scores. Omit domains not assessed unless clinically important. Do not infer sensitive information—document the source.)

Strengths/Protective factors: [Personal strengths, supportive relationships, coping skills, goals]

• Home: [Household composition, stability, safety, trusted adults]
• Education/Employment: [School performance, attendance, supports, work]
• Activities/Peers: [Friends, activities, screen time, online safety, bullying]
• Drugs/Substances: [Tobacco/vaping, alcohol, cannabis, other; frequency and context] [Screening: tool name and score if performed]
• Sexuality: [Gender identity, relationships, sexual activity, contraception, STI risk/prevention, consent/safety]
• Suicide/Depression/Mental Health: [Mood, self-harm, suicidal ideation/intent/plan/means; current treatment] [Screening: tool name and score if performed]
• Safety: [Safety at home/school/relationships, violence exposure, weapons access, injury prevention]

Acute safety concerns: [Ideation/plan/intent/means access; immediate actions taken; who notified; supervision plan; lethal means counseling; follow-up] (Only include if acute concerns identified)

Objective

(Only include if performed and relevant. Omit section entirely if no objective data obtained.)

• Vitals: [Relevant vitals]
• Exam: [Pertinent findings] (Note if exam declined or deferred)
• Testing: [Point-of-care tests and results: pregnancy, STI, toxicology, other]

Assessment

(Problem-oriented, ordered by urgency)

• [Problem 1]: [Clinical impression] — [Key risk/protective factors] — [Confidentiality constraints if applicable]
• [Problem 2]: [Clinical impression] — [Key risk/protective factors] (Add problems as needed)

Plan

(Mirror the Assessment)

• [Problem 1]: [Counseling/interventions, tests ordered, medications, referrals, safety plan and crisis resources]
• [Problem 2]: [As above] (Add problems as needed)

• Follow-up: [Interval and indications for earlier contact]
• Safe contact plan: [Verified method and any restrictions]
• Shared with caregiver: [Non-confidential items discussed]
• Retained confidential: [Categories kept confidential] (Do not include specifics if note may be visible)
• Confidentiality broken: [Trigger, what disclosed, to whom, support provided] (Only include if safety/mandatory reporting required disclosure)