Family Therapy Progress Note (Pediatric Psychology)

Date of Service: [Date]

Patient Name: [Patient name]

DOB: [Date of birth]

MRN: [Medical record number]

Visit Type: [Initial Family Therapy / Follow-up Family Therapy]

Session Number: [Session count]

Modality: [In-person / Video Telehealth / Audio-only]

Location: [Clinic site or patient's physical location if telehealth]

Participants Present: [Each person present with relationship to patient] (Explicitly note if the child/adolescent patient was present or absent.)

Consent/Confidentiality: [Guardian consent status, youth assent if developmentally appropriate, confidentiality limits reviewed, family information-sharing agreements] (Use explicit statements: obtained/declined/not assessed.)

Clinician: [Name, degree, credentials]

Supervising Clinician: [Name, degree, credentials] (Only include if applicable.)

Interval History

[Updates since last session: symptom/behavior changes, family/environmental updates, school/medical updates relevant to treatment] (Keep concise. Attribute each item to caregiver report, child report, clinician observation, or chart review.)

Homework Adherence: [Completion data with frequency, counts, or chart totals; barriers to implementation] (Use neutral, nonjudgmental language for barriers.)

Session Content

Session Focus/Structure: [Brief focus and format: child present, caregiver-only, or split segments]

Reports: [Subjective reports from child and caregivers on mood, concerns, triggers, behavior plan perspectives] (Attribute to source. Use direct quotes sparingly and only for safety-critical statements or key family agreements.)

Observations: [Child presentation: affect, engagement, regulation, behavior; Caregiver presentation: affect, responsiveness, co-parenting alignment; Family interaction patterns] (Use behaviorally specific, neutral language.)

Family/System Themes: [Systemic patterns addressed today as concise clinical formulation] (e.g., escalation cycles, reinforcement contingencies, accommodation patterns, co-parent inconsistency.)

Interventions: [Parenting interventions coached: psychoeducation topics, live coaching/modeling, skills practiced] (Document observable caregiver performance and child response.)

Behavior Plan Updates: [Changes to target behaviors, antecedent strategies, reinforcement schedules, consequences, or tracking methods] (Only include if plan was modified this session.)

Assessment

Progress: [Improving / Stable / Worsening] toward treatment goals with [1-2 supporting data points] (If minimal progress, briefly note barriers.)

Formulation: [Maintaining variables relevant to today: child factors, caregiver factors, environmental/system factors]

Medical Necessity: [Link diagnosis and symptom burden to functional impairment and need for skilled family-based intervention] (1-2 sentences.)

Safety

[Risk screening results: suicidal ideation, self-harm, aggression, abuse/neglect concerns as relevant to age and presentation; protective factors; risk level with brief rationale] (Always include at least a brief statement. Document any safety interventions performed: safety plan review, crisis resources, means safety, mandated report.)

Plan

Next Session: [Date/time if scheduled; recommended frequency; expected participants with rationale]

Between-Session Assignments:

• [WHO: family member] / [WHAT: specific skill or task] / [WHEN: frequency and context] / [HOW TO TRACK: tracking method] (Include troubleshooting guidance if applicable.)

Coordination: [Care coordination completed or planned: communications with pediatrician, school, psychiatrist, caseworker; referrals placed; release of information status] (Omit if no coordination occurred.)

Signature: [Name, credentials]

Date/Time Signed: [Date and time]