Family Psychotherapy Note (Child/Adolescent)

Patient: [name, DOB or MRN, age, preferred name/pronouns if collected]

Date of Service: [encounter date]

Service Type: Family Psychotherapy

Patient Present: [Yes / No / Partial] — (If No or Partial, include brief reason.)

Participants: [all attendees with relationship to patient; note clinically relevant absences]

Setting: [in-person / telehealth] (If telehealth, include patient location, clinician location, and others present in room.)

Session Duration: [length in minutes]

Clinician: [name, credentials]

Session Focus & Interval History

[Session focus linked to patient's treatment plan goals and medical necessity for family intervention] (Open with 2–3 sentences that explicitly connect today's work to treatment goals and justify the need for family-based care.)

[Interval updates since last contact] (Identify informant source: patient, caregiver, or both. Cover symptom and behavior changes, school and home functioning, adherence to prior home practice, and relevant stressors or protective factors. If key information was not obtained, briefly state reason.)

Observations

(Document observable behavior using functional, non-pejorative language. Clearly distinguish caregiver report from clinician observation.)

Patient presentation: [engagement, affect, behavioral regulation, notable triggers or soothing strategies observed] (Include only if patient attended session.)

Family interaction patterns: [communication dynamics, escalation sequences and responses, turn-taking, repair attempts] (When patient absent, focus on caregiver engagement and caregiver-to-caregiver interaction patterns.)

Assessment

[Clinical formulation of how family patterns relate to the child/adolescent's presenting concerns] (Describe how interactional dynamics maintain or alleviate symptoms.)

Status: [improving / unchanged / worsening] — [brief supporting evidence]. [Barriers to progress if relevant.]

Safety assessment: [Suicide/self-harm screening, violence risk, abuse/neglect concerns]. Risk level: [low / moderate / high] — [brief rationale]. (If elevated risk or significant history, document safety plan components reviewed and disposition. If low risk with no concerns, a brief statement is sufficient. If not assessed, state reason.)

Interventions & Plan

Interventions: [specific techniques used, including parent management skills coached, communication techniques practiced, psychoeducation provided, care coordination] (Avoid generic statements; name the specific skills taught or practiced.)

Response: [patient and caregiver engagement, observed skill use, ability to apply skills in-session]

Between-session goals: [specific tasks with assigned responsibility for caregiver and patient if developmentally appropriate; what will be tracked for review] (If no homework due to crisis focus, note stabilization plan instead.)

Next steps: [focus for next session, referrals or coordination needed, follow-up timing, urgent contact criteria if relevant]