This letter provides a brief summary of a first session, and a treatment plan, to a GP or other referrer. This template may also be appropriate if there is a need to summarise a shorter treatment period (of only a few sessions). If available, psychometric assessment results from NovoPsych can be integrated into the letter.
Re: Client’s Name; Client’s Date of Birth.
Dear Dr Referring Clinician’s Name,
Thank you for referring Client’s Name.
Provide a concise summary of the most important details about the client’s circumstances, diagnosis, and relevant information related to presenting issues. Consider including presenting issues, key background information, diagnoses, medical history, occupation, living arrangements, social support, trauma history, relevant people in the client’s life, and treatment goals.
Provide a brief summary of the treatment plan and any treatment already provided. Consider including therapy modality, session frequency, and any other treatment-related information discussed by the clinician. Include medication information if applicable.
Provide a summary of any psychometric assessments completed by the client.
If applicable, include any recommendations for referrals to other health professionals or services made by the clinician, along with the rationale. Include any requests for medication review and the reasons provided.
I will provide you with another update on the progress of treatment in due course. Should you have any further questions regarding Client’s Name, please feel free to contact me.
Sincerely,
Clinician Name
Clinician Profession
Practice Name
Re: Emma Thompson; DOB: 14/05/1992
Dear Dr Wilson,
Thank you for referring Emma Thompson.
Ms Thompson presented with symptoms consistent with panic disorder with agoraphobic features, experiencing 3-4 panic attacks weekly in public settings, particularly shopping centres and public transport. She reports the first episode occurred 8 months ago, with increasing frequency and avoidance behaviours over the past 3 months significantly impacting her daily functioning. Ms Thompson has reduced her work hours as an administrative assistant and is withdrawing from social activities due to anticipatory anxiety. She denies suicidal ideation or self-harm and has no significant medical history.
We have commenced a 10-session course of Cognitive Behavioural Therapy with weekly appointments, focusing on psychoeducation about panic, cognitive restructuring of catastrophic misinterpretations, and graded exposure to avoided situations. Ms Thompson has shown good insight into her condition and motivation for treatment, with goals to reduce panic frequency, develop effective management strategies, and gradually return to avoided activities.
Psychometric assessment using the Depression Anxiety Stress Scale (DASS-21) indicate clinically significant levels of psychological distress, with anxiety symptoms being particularly elevated, in the severe range. Her depression and stress scores fall in the moderate range.
I will provide you with another update on the progress of treatment in due course. Should you have any further questions regarding Emma Thompson, please feel free to contact me.
Sincerely,
Dr Joe Taylor
Clinical Psychologist
The Psychology Centre
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