Caregiver Consultation Note (Play Therapy)

Date of Service: [Date of service]

Patient (Child): [Name], [DOB], [MRN]

Session Time: [Start time – Stop time / Total face-to-face minutes]

Service Type: [Family psychotherapy without patient present / Caregiver consultation]

Participants: [Caregiver name(s) and relationship to child; custody status if clinically relevant]

Setting: [in-person / telehealth] (If telehealth, note HIPAA-compliant platform and locations)

Provider: [Provider name, credentials]

Relevant Diagnoses (Child): [Diagnoses relevant to this encounter]

Reason for Visit & Confidentiality Review

[Caregiver-stated reason for session and clinical indication for caregiver-only visit] (e.g., aligning home strategies with play therapy goals, addressing behavioral escalation, care coordination)

[Confidentiality boundaries reviewed] (Confirm in 1–2 sentences what is routinely shared with caregivers versus what remains protected unless safety concerns arise; note release authorization status if care coordination discussed)

Caregiver Report

[Caregiver's observations of child's functioning since last contact] (Include current concerns with behavioral descriptions, noted improvements or strengths, relevant home routines and parenting patterns, school/daycare functioning by report, and adherence to prior home practice recommendations. Attribute all information as caregiver report. Note caregiver stressors only as they directly impact treatment adherence or parenting capacity.)

Assessment

[Clinical synthesis of play therapy progress and child's status] (Provide 1–2 paragraphs. Include general themes and skill development shared with caregiver without disclosing sensitive child content. State progress toward treatment goals.)

[Risk assessment by caregiver report] (Document safety concerns as reported with explicit attribution and protective factors identified. If none: "Caregiver denied current safety concerns; child not present for direct assessment.")

[Medical necessity statement] (Explain why caregiver-focused intervention is required to address the child's condition)

Plan

Interventions delivered: [Parenting strategies discussed/coached; psychoeducation provided]

Home practice plan: [Specific behavioral targets, frequency, and tracking method]

Care coordination & referrals: [Actions with other providers, authorization status, crisis resources reviewed] (Include only if applicable)

Follow-up: [Next child session, next caregiver consultation timing, general themes to share with child next session if applicable]

Provider Signature: [Name, credentials, date/time]

(Include supervisor co-signature if required by training status)