Title X Minor Services Documentation Form

Documents counseling provided to a minor under Title X, including required screening for coercion, abuse, safety concerns, and referral actions while minimizing collection of unnecessary PII.

Encounter Details

• Date of Counseling
• Service Setting
• Counseling Topic
• Other Topic Details
• Brief Counseling Summary
  Document only what is necessary to support care, compliance, and the audit trail. Avoid unnecessary PII.

Minor Confidentiality and Presence

• Was the minor seen alone for at least part of the visit?
• Was confidentiality and its limits reviewed?
• Was a parent or guardian present?
• Notes on Who Was Present

Coercion and Abuse Screening

• Was screening for coercion completed?
• Was screening for abuse or safety concerns completed?
• Screening Result
• Type of Concern Identified
• Brief Concern Details
  Include only factual observations and statements needed for care, reporting, and the audit trail.

Actions Taken

• Was an immediate safety plan discussed?
• Referrals Made
• Referral Details
• Is follow-up required?
• Follow-Up Date

Consent and Submission

• I documented only the minimum necessary information and understand this record may contain PII.
• Were consent and disclosure requirements reviewed with the minor as appropriate?
• Completed By
• Job Title