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Run: Title X Minor Services Documentation Form

Document Title X counseling for a minor, including confidentiality review, coercion and abuse screening, and any referrals or follow-up actions. Built to cap...

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Encounter Details

Date of Counseling (required)

Service Setting (required)

Counseling Topic (required)

Minor Confidentiality and Presence

Was the minor seen alone for at least part of the visit? (required)

Was confidentiality and its limits reviewed? (required)

Was a parent or guardian present? (required)

Notes on Who Was Present

Coercion and Abuse Screening

Was screening for coercion completed? (required)

Was screening for abuse or safety concerns completed? (required)

Screening Result (required)

Type of Concern Identified (required)

Brief Concern Details (required)

Include only factual observations and statements needed for care, reporting, and the audit trail.

Actions Taken

Was an immediate safety plan discussed? (required)

Referrals Made (required)

Referral Details

Is follow-up required? (required)

Follow-Up Date

Consent and Submission

I documented only the minimum necessary information and understand this record may contain PII. (required)

Yes No N/A

Were consent and disclosure requirements reviewed with the minor as appropriate? (required)

Completed By (required)

Job Title

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Email (required)

Your name (optional)

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