Treatment Summary & External Request Letter (US)
Letter Template:
This flexible clinical treatment summary template drafts a formal letter tailored to common administrative and external requests. It adapts its opening statement and clinical focus based on the clinician’s instructions to support workplace or leave support requests, external referrals (e.g. psychiatry, specialty services, or specialized testing), insurance prior authorizations, or a general clinical treatment summary.
This template can be used via NovoNote’s “Create Document” tool to integrate psychometric results in NovoPsych, previous sessions in NovoNote, and additional contextual information such as session notes, prior assessments, treatment plans and other provided client records.
Date
Re: Client Name
DOB: Date of Birth
Purpose:
- One to two sentences naming the treating clinician (name, role, credentials), the diagnosis, the treatment period, and the purpose of the letter: referral for further care; insurance prior authorization or continued care; workplace or leave support; or general treatment summary.
Treatment Provided:
- Number of sessions to date and frequency.
- Modality and interventions used.
- Client engagement and therapeutic alliance, when documented.
- Medications, when documented.
- Response to treatment to date.
Assessments:
- One to two sentences covering administered objective measures, scores, and severity or specifiers, tied to the clinical picture.
Clinical Rationale and Justification:
- Acute documented symptoms supporting the request.
- Functional impairment in the life areas actually supported by the source (activities of daily living, work or school, interpersonal, physical health), with one or two brief examples.
- Any relevant risk assessment, including self-harm, suicidal or homicidal ideation and substance use, reported exactly as documented.
Closing:
- Statement of clinical goals and a note of the ongoing treatment plan, when relevant.
Kind regards,
Clinician Name, Clinical Profession, Credentials
Date: September 4, 2026
Client Name: Mary Blogs
DOB: March 12, 1990
I, Dr. Sarah Chen, clinical psychologist (PsyD), have been treating Mary Blogs for Generalized Anxiety Disorder since March 2025. Referral is requested for standardized neuropsychological testing to differentiate anxiety-related concentration difficulties from a possible underlying attentional disorder.
Mary has attended twenty-two individual sessions on a weekly basis, engaging in Cognitive Behavioral Therapy with a focus on cognitive restructuring and graded exposure. She has maintained a strong therapeutic alliance throughout and has consistently completed between-session tasks. Her anxiety symptoms have shown a gradual but steady reduction over the course of treatment, though concentration difficulties have persisted despite this improvement.
Mary’s presentation is currently consistent with moderate anxiety, specified as generalized. Her most recent GAD-7 score was 11, down from a baseline of 17, indicating that anxiety severity has improved while attentional symptoms have not tracked with this change, a pattern that supports the need for differential assessment.
Mary continues to report difficulty sustaining attention across tasks, frequently losing her train of thought mid-conversation, and describes this as distinct in character from her earlier anxiety-driven worry.
These attentional difficulties are affecting Mary’s day-to-day functioning. She has noted missing deadlines at work despite reduced anxiety, and has described needing to re-read materials multiple times to retain information. Risk was assessed during the most recent session and no suicidal or self-harm ideation, intent, or plan was identified.
This letter summarizes Mary’s treatment course to support a referral for neuropsychological testing to clarify whether her ongoing attentional difficulties reflect a separate underlying condition rather than a residual feature of her anxiety disorder. Weekly individual sessions will continue alongside this referral.
Please feel free to contact me if you would like to discuss.
Kind regards,
Sarah Chen, PsyD
Licensed Clinical Psychologist
License No. PSY0001234
- Template Type
- Report
- Letter
- Administrative
Author:
Dr Liz Rojas
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