For use by a psychiatrist seeing a patient for the first time or for a longer appointment, this NovoNote template provides a structure for a detailed formal letter to be forwarded to the referrer (GP) following an initial clinical interview and assessment appointment. It includes information captured by the Psychiatric Clinical Interview and Assessment template, and converts this information into a structured, clinically appropriate letter.
In Australia, it would be suitable to use under MBS Item 291, and other MBS Item Numbers for longer appointments.
Note: For letters relating to previously seen patients, it is recommended that other templates with less background information be used, such as the Psychiatrist Letter to Referrer – General Review Appointments template.
Dr Referring Clinician’s Name
Referring Clinician’s Address
Re: Patient name, DOB Patient date of birth, Patient address
Dear Referring Clinician’s Name,
Thank you for referring Patient’s Name for a psychiatric assessment.
Provide a brief summary of the presenting problem or purpose of the appointment, including type and nature of symptoms, length of time with symptoms, external stressors, interpersonal or relationship factors, and impact on functioning.
Personal and Developmental History:
Current Key Lifestyle Indicators:
Medical Status and Medical History:
Psychiatric Illness History:
Medication History:
Drug and Alcohol Use History:
Other Addiction History:
Legal and Forensic History:
Mental Status Examination (MSE):
Strengths, Coping Skills, Recreational Interests, and Hobbies:
Psychometric Testing:
Formulation / Impression:
Diagnosis:
Risk:
Treatment Plan Discussed With Patient:
Summary:
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Psychiatrist Name
Dr James Jones
NovoPsych Medical Centre
1 Station Road
Carlton VIC 3053
Re: Mary Blogs, DOB 15/08/1985, 1 NovoNote Street, Parkville VIC 3052
Dear Dr Jones,
Thank you for referring Mary Blogs for a psychiatric assessment.
Mary presents with a three-month history of persistent low mood, anxiety, and sleep disturbance following the breakdown of her marriage and subsequent divorce proceedings. She reports significant anhedonia, social withdrawal, and difficulty concentrating at work as a primary school teacher, with symptoms intensifying during custody negotiations regarding her two young children. Mary describes feeling overwhelmed by single parenting responsibilities while managing her teaching workload, leading to decreased performance and concerns from her school principal about her wellbeing.
Personal and Developmental History:
Mary grew up in a stable two-parent household as the eldest of three children, achieving well academically and completing a Bachelor of Education before marrying at age 25. She has two children aged 6 and 8 years and currently lives in the former family home with limited financial support from her ex-husband. Significant childhood trauma includes witnessing domestic violence between her parents from age 8-12, with her father’s alcoholism and verbal aggression toward her mother before her parents divorced when she was 13. Mary reports taking on a caretaking role for her younger siblings during this period and feeling responsible for her mother’s emotional wellbeing. Family history is notable for maternal depression requiring hospitalisation when Mary was 15, and paternal history of alcohol use disorder.
Current Key Lifestyle Indicators:
Mary’s sleep pattern is severely disrupted with difficulty falling asleep until 2-3 AM and early morning waking at 4 AM, resulting in only 3-4 hours sleep nightly. Her diet consists mainly of convenience foods with frequent meal skipping, increased caffeine intake of 4-5 cups coffee daily, and occasional binge eating episodes. Physical exercise has ceased completely since the marriage breakdown, though she previously walked regularly for stress management. Social functioning is significantly impaired with complete withdrawal from friendships and family relationships, avoiding social situations and declining invitations from previously close friends.
Medical Status and Medical History:
No significant medical conditions reported aside from recurrent headaches since onset of current episode. Mary currently takes no regular medications though reports frequent use of over-the-counter pain medication for headaches.
Psychiatric Illness History:
No previous psychiatric diagnoses or formal treatment. Brief episodes of anxiety during university exams and again during her mother’s hospitalisation but did not seek professional help. Reports period of low mood lasting several months following birth of second child but attributed this to normal adjustment difficulties.
Medication History:
No current or previous psychotropic medications. Occasional use of paracetamol and ibuprofen for headaches with good response and no adverse effects reported.
Drug and Alcohol Use History:
Alcohol consumption has increased to 2-3 glasses of wine nightly since separation, occasionally up to a full bottle on weekends. No tobacco use or illicit substance use reported, though Mary acknowledges concern about her current drinking pattern and its potential impact on her mood and sleep.
Mental Status Examination (MSE):
Strengths, Coping Skills, Recreational Interests, and Hobbies:
Mary demonstrates strong dedication to her children’s wellbeing and maintains their routines despite personal distress. She previously enjoyed reading historical fiction and gardening before the current episode and shows good problem-solving skills in her professional teaching role. Mary has a strong work ethic and commitment to education, respected by colleagues and parents, and demonstrates resilience through her ability to continue working despite significant emotional difficulties.
Formulation / Impression:
Mary’s presentation represents a major depressive episode with anxiety features precipitated by marital breakdown and divorce proceedings. Predisposing factors include childhood exposure to domestic violence and parental mental illness, creating vulnerability to relationship trauma and tendency toward self-blame. Her history of taking on caretaking roles from an early age contributes to current feelings of failure when unable to maintain her marriage. Precipitating factors include her husband’s departure and ongoing legal stress. Perpetuating factors include social isolation, disrupted sleep, increased alcohol use, and rumination about personal inadequacy. Protective factors include her commitment to her children, stable employment, and good insight into her difficulties.
Diagnosis:
Major Depressive Disorder, single episode, moderate severity (DSM-5-TR: 296.22, ICD-11: 6A70.1). Secondary diagnosis of Alcohol Use Disorder, mild severity (DSM-5-TR: 303.90, ICD-11: 6C40.0) – emerging pattern requiring monitoring. These are new diagnoses with no previous psychiatric history.
Risk:
Mary denies current suicidal ideation but reports passive thoughts that “everyone would be better off without me” and occasional fleeting thoughts of driving into oncoming traffic, though she states she would never act on these due to her children. No history of suicide attempts or deliberate self-harm behaviours. Current high-risk factors include ongoing custody stress, financial pressures, social isolation, and increased alcohol use. Protective factors include strong maternal bond with her children, maintaining employment, and seeking help voluntarily.
Treatment Plan Discussed With Patient:
Commence sertraline 50mg daily with plan to review in two weeks and titrate to 100mg as needed, with discussion of common side effects and importance of adherence. Referral to psychologist specialising in trauma and depression for cognitive behavioural therapy focusing on processing childhood trauma and current adjustment difficulties. Recommendation for GP review to assess physical health, address headaches, and monitor alcohol consumption with brief intervention. Follow-up appointment scheduled in two weeks to monitor medication response and symptom improvement. Safety planning discussed with instruction to contact crisis services if thoughts of self-harm emerge. Recommend monitoring alcohol consumption and providing brief intervention for emerging alcohol use concerns.
Summary:
Mary presents with major depressive disorder triggered by marital breakdown, with underlying vulnerability related to childhood trauma exposure and emerging alcohol use concerns. She demonstrates good insight and motivation for treatment despite significant current distress. Comprehensive treatment plan includes antidepressant medication, psychological therapy, and close monitoring of risk factors.
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Sarah Smith
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