A concise letter to a psychiatrist providing updates on a shared patient. The letter summarises relevant clinical information including current presentation, treatment progress, and any matters requiring the psychiatrist’s attention. The letter uses psychiatric terminology and is formatted to respect the psychiatrist’s time while providing clinically meaningful information. It is recommended that the Additional Context box be used to state the purpose of the letter when creating this document, as the template has been designed to frame the letter around any stated purpose.
Re: Patient’s Name
DOB: Patient’s Date of Birth
Dear Dr Psychiatrist’s Last Name,
Purpose of correspondence:
Current presentation:
Treatment summary:
Psychometric assessment results:
Medication observations:
Risk assessment:
Clinical recommendations or queries:
Ongoing care:
I trust this information is helpful for patient’s name’s ongoing psychiatric management. Please contact me if you require any further information or wish to discuss patient’s name’s care.
Kind regards,
Clinician Name
Clinician Profession
Re: Emma Brown
DOB: 14 March, 1991
Dear Dr Smith,
Purpose of correspondence:
I am writing to provide a treatment update regarding Emma Brown and to request a review of her current medication in light of a recent change in her clinical presentation.
Current presentation:
Emma presents with a moderate-to-severe depressive episode characterised by persistent low mood, anhedonia, psychomotor retardation, and significant sleep disturbance. She reports marked functional impairment across occupational and social domains, with recent difficulty sustaining attendance at work. Her anxiety symptoms have also escalated over the past four weeks, with heightened somatic complaints and avoidance behaviour. There have been no acute risk concerns identified at this time.
Treatment summary:
Emma has been engaged in weekly individual Cognitive Behavioural Therapy with me since February 2024, with 12 sessions completed to date. Treatment has focused on behavioural activation, cognitive restructuring, and anxiety management strategies. Emma’s engagement has been consistent and her therapeutic alliance is strong; however, her mood symptoms have not improved to the degree anticipated, and functional gains have been limited. Given the plateau in her treatment response, a psychiatric review is considered warranted at this stage.
Psychometric assessment results:
Medication observations:
Emma reports taking her current antidepressant medication as prescribed, though she describes limited subjective benefit and ongoing fatigue she attributes to the medication. She has not reported any significant adverse effects but has expressed ambivalence about continuing the current regimen.
Clinical recommendations or queries:
I would be grateful for your review of Emma’s current pharmacological management given her limited response to treatment and recent symptomatic deterioration. Specifically, I would welcome your opinion on whether an adjustment to her current medication or consideration of augmentation strategies may be appropriate to support her ongoing recovery.
Ongoing care:
I will continue to provide weekly CBT sessions with a focus on consolidating coping strategies and addressing avoidance behaviours.
I trust this information is helpful for Emma’s ongoing psychiatric management. Please contact me if you require any further information or wish to discuss her care.
Kind regards,
Mary Blogs
Clinical Psychologist
Share
See how mental health professionals have transformed their practice with NovoNote.
