Progress Notes for Child and Adolescent Therapy: Example and Template
How to write a progress note for a child or teen therapy session: what to document, a fictional worked example that separates the child’s and caregiver’s reports, and answers to common questions about parents, play therapy and safety.
Quick Answer
A child or adolescent progress note records who attended, what the child and the caregiver each reported (attributed separately), what you observed, the developmentally adapted intervention and its purpose, how the child responded, any safety concerns, and the plan, including caregiver and school follow-up. Write specific, goal-linked statements: “practiced naming three early frustration cues to support the emotional-regulation goal” is much stronger than “worked on coping skills.”
Overview
This guide is part of our complete progress notes hub — format structure, a full clinical example, the progress note generator, and all 72 diagnosis-specific templates.
No sign-up needed: open a fictional note in the MentalNote editor and edit it like a real draft.
Notes for children and teens differ from adult notes in three ways: information comes from several people (the child, caregivers, sometimes the school), interventions are adapted to the child’s developmental level, and consent, confidentiality and mandated reporting rules apply. The table shows what to capture.
What to document in a child or adolescent progress note
| What to document | Example wording |
|---|---|
| Who attended and for how long | “Client (age 10) attended with parent (legal guardian); 10 minutes joint, 35 minutes individual.” |
| Caregiver report, attributed | “Parent reported school-morning refusals on 2 of 5 days this week (4 of 5 the week before).” |
| The child’s report in their own words | “Client said mornings feel ‘scary.’” |
| School or other collateral, with authorization noted | “School counselor reported (authorization on file) that client arrived on time 4 of 5 days.” |
| Observations: affect, engagement, play themes, developmental fit | “Engaged for most of session; became quiet when school was discussed, then re-engaged through drawing.” |
| Intervention, how it was adapted, and its purpose | “Used a feelings thermometer and role-play with figures to rehearse a coping-card routine for school mornings (anxiety goal).” |
| Response, measured where possible | “Rated morning worry 6/10 (8/10 at intake); demonstrated slow breathing with one prompt.” |
| Safety and mandated-reporting screening | “Asked in age-appropriate language about feeling unsafe or hurting self: denied. No reportable concerns.” |
| Plan, including caregiver role and coordination | “Parent to prompt coping card and track refusals; clinician to contact school counselor; next session in 1 week.” |
How to Document Progress Notes for Child & Adolescent Therapy
Session Summary
Overview of session focus, topics discussed, and client presentation
When documenting the Session Summary for a child or adolescent, capture the primary concerns expressed by the client including any reported symptoms, emotional states, and situational triggers observed during the session.
- Document specific client-reported symptoms such as anxiety, irritability, or withdrawal.
- Note presenting concerns raised by the child or adolescent including social, academic, or familial stressors.
- Identify any situational or environmental triggers contributing to mood or behavior changes.
- Describe observed mood and affect, noting congruence or incongruence with reported feelings.
- Summarize changes or patterns in behavior since the last session as reported by the client.
Interventions
Therapeutic techniques and interventions applied during the session
In the Interventions section, detail the therapeutic techniques, clinical observations, and modalities applied during the session tailored to the developmental needs of the child or adolescent.
- List specific therapeutic approaches used such as play therapy, cognitive-behavioral techniques, or art therapy.
- Record notable clinical observations related to engagement, attention span, or cooperation during interventions.
- Describe any use of psychoeducation provided to the child or caregiver.
- Note adaptations made to interventions to accommodate developmental level or emotional state.
- Identify any collaborative activities or family involvement integrated into the session.
Client Response
Client's reaction to interventions and observable progress
The Client Response section should capture the child or adolescent's reactions to interventions, progress toward treatment goals, and any diagnostic impressions noted during the session.
- Evaluate the client’s level of engagement and responsiveness to therapeutic techniques.
- Assess observable changes in behavior or emotional regulation since prior sessions.
- Document client’s verbal or nonverbal feedback regarding the interventions used.
- Note any emerging diagnostic considerations based on session observations and client report.
- Record clinical impressions regarding motivation, insight, and readiness for change.
Plan Updates
Changes to treatment plan, goals, and next session focus
In the Plan Updates section, outline the next steps in treatment, including modifications to the therapeutic approach, homework assignments, referrals, and scheduling considerations specific to the child or adolescent.
- Specify adjustments to treatment goals or therapeutic techniques based on current progress.
- Assign developmentally appropriate homework or skill-building activities for the client.
- Recommend referrals to additional services such as educational support or psychiatric evaluation if indicated.
- Outline plans for caregiver involvement or family sessions if appropriate.
- Confirm scheduling of future sessions and any changes to frequency or format.
Child progress note example
Fictional documentation example, not treatment guidance. Adapt it to the session you actually conducted and your organization’s requirements.
Session Summary: Fictional 10-year-old client attended with a parent (legal guardian); 10 minutes joint, then 35 minutes individual. Treatment-plan goal: attend school on 5 of 5 mornings with worry rated 4/10 or lower. Parent reported school-morning refusals on 2 of 5 days this week (4 of 5 the week before) and one tearful drop-off. Client said mornings feel “scary” because “I might feel sick at school.”
Interventions: Used a 0–10 feelings thermometer and a drawing of the “worry” to help the client talk about morning worry. Through role-play with figures, rehearsed a coping-card routine for school mornings: two coping statements and three slow breaths. Gave the parent brief psychoeducation on keeping drop-off short and predictable and praising brave behavior.
Client Response: Client rated morning worry 6/10 (8/10 at intake), chose two coping statements for the card (“I can feel worried and still go” and “The worry gets smaller after I start”) and demonstrated the slow breathing with one prompt. Engaged for most of the session; became quiet when the school nurse was mentioned, then re-engaged through drawing. Parent agreed to prompt use of the card.
Safety: Asked in age-appropriate language about feeling unsafe at home or school and about wanting to hurt himself: client denied. No reportable concerns identified.
Plan Updates: Client will use the coping card each school morning and the parent will record refusals on a simple chart. With the guardian’s written authorization on file, clinician will contact the school counselor about a consistent arrival routine. Next session in one week to review the chart.
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Tips for Progress Notes for Child & Adolescent Therapy
1. Attribute every source
Label what the child said, what the caregiver reported and what the school reported, and keep each separate from what you observed. Note when information came by phone or email and whether an authorization was needed.
2. Record consent, assent and confidentiality limits
Note who holds the right to consent, that the child or teen assented, and what you explained about confidentiality and its limits. Rules on minors consenting to their own treatment and on parental access differ by state.
3. Describe play and activities concretely
Write what the child did, the theme you noticed, what you did and why (“used role-play with figures to rehearse asking the teacher for help”), and how the child responded. Present interpretations as your clinical impression, not fact.
4. Measure the same way over time
If you use a standardized measure such as the SDQ or SCARED, give it at set points and record the score, the date and who completed it (child, parent or teacher). Do not paste the items into the note.
5. Document disclosures and reports precisely
If a child discloses possible abuse or neglect, record the child’s words, the context, who was present, the report you made (agency, date and time, reference number) and any consultation. Mandated-reporting rules differ by state.
6. Write the plan around the people involved
Say what the child will practice, what the caregiver will do, any school or pediatrician coordination and the authorization it relies on, and when you will review progress.
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Further Reading
- APA Documentation Guidelines — Provides detailed guidance on clinical documentation practices relevant to mental health professionals.
- SAMHSA — Offers resources on behavioral health documentation and best practices for treatment planning.
- HHS HIPAA — Details legal requirements for protecting patient information in clinical documentation.