Group Psychotherapy Note (Child/Adolescent)

Patient: [name, MRN/ID, DOB or age]

Date of Service: [date]

Service: Group Psychotherapy (Child/Adolescent)

Session Time: [start time – end time, total minutes]

Facilitator(s): [name(s) and credentials]

Group: [group name/type]

Attendance: [present / late / left early]; [minutes attended]

Group Size: [number of participants present]

Group Session Summary

[Session theme and interventions used] (Summarize in 2–4 sentences. Include skills or topics addressed and modalities used such as CBT cognitive restructuring, role-play, mindfulness, or behavioral rehearsal. Do not include any identifying information about other group members.)

Patient Participation and Response

Participation: [engagement level and observable behaviors] (Describe engagement as [active / moderate / minimal / withdrawn] with specific behavioral evidence. Note prompts needed, skills practiced, or difficulties encountered. Use objective, non-judgmental language.)

Presentation: [relevant mental status observations] (Document mood, affect, attention, impulse control, and peer interaction style as observed. Distinguish clinician observations from patient self-report using "Appeared..." versus "Patient stated...")

Response to Interventions: [link interventions to patient outcomes] (Describe how specific techniques influenced the patient's participation or skill acquisition, including coaching effects and skill rehearsal outcomes.)

Progress Toward Treatment Goals: [improved / unchanged / worsened] (Reference the patient's individualized treatment plan goals relevant to this session. Provide brief supporting evidence from behaviors or statements. Note barriers if observed.)

(When referencing peer interactions, use only non-identifying language such as "a peer" or "another group member.")

Safety

Risk Assessment: [No acute safety concerns endorsed or observed today. / Safety concerns present: [description]] (Address suicidal ideation, self-harm, homicidal ideation, aggression, and abuse/neglect. Include both patient endorsements/denials and clinician observations.)

Actions Taken: [safety plan updates, guardian notification, crisis resources, referrals] (Include only if safety concerns are present; otherwise omit this line.)

Plan

Next Session: [date/time or frequency]

Homework/Practice: [assigned skill practice or task] (Omit if none assigned.)

Coordination: [planned contact with guardian, school, or other providers] (Omit if not applicable.)

Treatment Plan Updates: [modifications to goals or interventions] (Omit if none.)

(Ensure documentation is individualized, demonstrates medical necessity, and avoids transcript-like detail. Never include names, initials, ages, schools, or unique identifiers of other group members.)