Therapists often have to collaborate with a treatment team in order to provide the best possible care. This can include writing a referral letter to a psychiatrist. When writing a referral letter there is a specific format that therapists are expected to follow.
Basic Client Information
Here is what you will need to include and the proper order for it to go in. Begin by identifying yourself and your client. You will want to have the client’s name, age, occupation and any other important identifying information. You should mention how long you have been meeting with the client for. In the first paragraph you also want to identify the reason you are writing this referral letter.
Presenting Problem
The next paragraph should be devoted to the presenting problem. You will want to talk about the problem as it is currently presenting itself. You should also include any information about how the client’s life or functioning is being impacted by the issue.
History of Problem
Continue your referral letter by discussing the history of the presenting problem. If you have the information include when it first started and if there was any major life event around that time. Next include any information about past psychiatric diagnoses, hospitalizations.
Client’s Personal History
In the next paragraph you should talk about the client’s personal history. This will include information like relationship status, employment, and weather or not they have children. It is also important to mention any history of substance abuse or trauma. The final thing you will note in this section is social support. This might mean talking about the client’s ties to their community, friends, or family.
Clinical Assessment
You can continue your referral letter with your subjective assessment of how the client presented in session. This means you will include the client’s orientation, mood, affect, insight, thought content, thought process, speech, and appearance. It is crucial that in this section you note your suicide assessment. Even if the client does not present with any suicidal ideation you MUST make note of it.
Medical History
The next section includes any known medical history. This becomes especially important if the client is coping with a chronic illness. You will also want to say if the client has a primary care provider and roughly how often they visit that provider.
Differential Diagnosis
The last chunk of information you want to include is your differential diagnosis. That means even if you are not sure what the diagnosis is, include the things that it might be. The psychiatrist will do their own diagnostic assessment, but it is helpful for them to have your thoughts as well.
Below I have included a sample referral letter to a psychiatrist from a counselor. This includes information about a fictional client.
March 30, 2017
To: John Smith, MD
100 Anywhere Street
Any City, CA 90000
From: Elizabeth Sockolov MFT Trainee
123 Somewhere Court
Any Town, CA 90000
Elizabeth@OneMindTherapy.com
Re: Jane Doe
DOB: 1/29/1985
Dear Dr. Smith,
My name is Elizabeth Sockolov and I am a therapist trainee working with Jane Doe. Enclosed is a signed release of information that allows us to share her information. The client is a 32 year old white female who is an undergraduate student at Sonoma State. I have had two sessions with the client in the past two weeks. During our last session I asked that she make an appointment with you to evaluate her worsening psychotic symptoms.
Ms. Doe’s symptoms started two months ago when she started having the persistent belief that her ex boyfriend was following her. She said that “she knew he was watching her” everywhere she went. Additionally, she felt that when she watched TV he was trying to send her threatening messages communicated in the shows that she watches. The client reports that these thoughts are causing her a great deal of distress and she has missed many classes in the past two months due to her staying in her apartment because she is scared that she will see him.
The client started experiencing these symptoms roughly a month after her break up with her boyfriend. She said she broke up with him because she felt increasingly worried that he was spying on her. The client felt that her boyfriend was accessing her phone and computer remotely while she was at school. These worries eventually led to her break up with the her boyfriend. She says that once they broke up her she became “obsessed” with the thought that he was stalking her and trying to communicate with her as stated above. She is now seeking help because it has gotten to the point where she has been missing class and recently she has started missing work as well.
The client does not have a previous diagnosis of a schizophrenia spectrum or other psychotic disorder. However, she says that when she was 18 she can had symptoms that were similar to how she feels now. She was about to leave for college when she became worried that people at the school were plotting against her. She even began hearing voices. Her parents did not want her to see a doctor or go to the hospital but they did convince her not to go to college. Instead, she got her associates degree closer to home. She says that once she was less stressed and comfortably living at home with her parents the symptoms became less invasive. She has never been hospitalized and has never taken medication. She reports this as the only other time she was worried about her symptoms. However, she says that during times of stress she has had thoughts that people are plotting against her or trying to hurt her. These thoughts usually become less intense when the life stressors are no longer present.
The client is now single but she was with her last boyfriend for over five years. They met at her job at sunglass hut where he was a customer. He convinced her to try to go finish her undergraduate degree and five months ago she began classes at Sonoma Sate. The client has no children. She has no past history of substance abuse or trauma. She has very few friends and little social support aside from her parents who she relies on for some financial support as well. Her parents are conservative and she reports that it is unacceptable in her family to seek mental heath help. She does not want her parents to know that she has been seeing a therapist as she is concerned that they would reject her and stop supporting her financially.
Ms. Doe was oriented by four in our sessions. Her thinking was ruminative and delusional. She did not report any auditory hallucinations. Her mood was highly anxious and she had trouble sitting in her seat during our sessions. She showed a full range of affect. She says she does not have any suicidal or homicidal ideation and that she never has in the past. Her insight is poor to fair. She has a sense that her delusional thoughts are abnormal but she also “cannot help believing them”. She is mainly seeking help because she wants to be able to go to work and class without any problems.
The client has no known medical problems. However, she goes to the doctor infrequently. I have also asked her to go to a primary care physician for a routine check-up. She has no history of any medical conditions.
My working diagnosis is:
Delusional Disorder, persecutory type, multiple episodes, currently in acute episode
Schizophrenifrom Disorder, with good prognostic features
Schizoaffective Disorder, multiple episodes currently in acute episode
Following your assessment I would appreciate if you would share your evaluation with me. If you do prescribe medication please provide a list of medication. I will help monitor medication compliance and keep you informed about her progress and any side effects.
Please feel free to contact me if you require any additional information. I am happy to be of further assistance to you. You can contact me at the above address or email address. I look forward to working with you so that we can be of the most help to Ms. Doe.
Thank you,
Elizabeth Sockolov
