Sample Referral Letter to a Psychiatrist from a Counselor

Sample Referral Letter to a Psychiatrist from a Counselor

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

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.

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