A treatment summary letter is the letter a therapist writes, with the client’s written consent, to tell another provider what treatment covered: the dates, the reason, the approach, progress on measures, current risk, and what you recommend. Copy the free letter or download it, see a handover to a new therapist and an update to a family physician, and check what to leave out.
Blank treatment summary letter template
FreeTREATMENT SUMMARY LETTER [Practice name] [Address, phone, and secure email or fax] Date: [Date of letter] To: [Recipient's name, role, and organization] [Address, secure email, or fax] Re: [Client's full name] Date of birth: [Date] Dear [Recipient's name], [Client's first name] asked me to send you a summary of their treatment with me, so that [the purpose, such as you can continue their therapy, or you can review their medication]. CONSENT Written consent signed on: [Date] It names: [You, and anyone else it names] It covers: [What I may share, such as dates, diagnosis, scores, risk, and recommendations] It ends on: [Date or event] TREATMENT Dates: [First session] to [last session, or ongoing] Sessions: [Number attended, and any missed or cancelled] Format and frequency: [In person, video, or both; weekly or every two weeks] Referred by: [Self, physician, or other source, and the reason they gave] Approach: [The model used, such as CBT, IPT, or EMDR, and the main work done] Medication: [Prescriber and current medication as the client reports it, or none] REASON AND DIAGNOSIS Presenting concerns: [The main problems at the start, in a few lines] Diagnosis: [Working diagnosis, if the client agreed to share it, or not included] PROGRESS Measures: [Each measure, with its first score, latest score, and dates] What has changed: [What the client can do now that they could not at the start] Still to work on: [Goals that remain open] CURRENT STATUS AND RISK At the last session: [Symptoms, functioning, and engagement] Risk: [Date of the latest risk assessment; suicidal thoughts, self-harm, and harm to others; the safety plan if one is in place] RECOMMENDATIONS [What I recommend, such as continued therapy at a set frequency and focus, a medical review, or a referral] Questions for you: [Anything I would like your view on, or none] NOT INCLUDED This letter does not include my session notes or what [client's first name] shared in sessions beyond this summary. More can be shared with their further written consent. Please use this summary only for the purpose above, and don't pass it on without [client's first name]'s consent. You can reach me at [phone or secure email]. Sincerely, [Your name, credentials] [License or registration number] [Signature] Sent by: [Secure email, fax, portal, or mail] on [date sent] Copy to client: [Yes, and how, or no]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Private practice psychologist to a psychologist in the client’s new city, after 12 sessions of CBT
Daniel, 29, moved for a new job at the end of October 2026, before his therapy was finished. He booked an intake with Dr. Mei Lin, a psychologist in his new city, for Thursday, November 12, and asked his therapist to send her a summary.
Dear Dr. Lin, Daniel asked me to send you a summary of his treatment with me, so that you can continue his therapy. He signed a release on Tuesday, October 6, 2026, naming you. It covers dates, diagnosis, scores, risk, and recommendations, and a phone call between us. It ends on April 30, 2027.
12 sessions from Tuesday, June 2, to Tuesday, October 6, 2026: weekly for 8 sessions, then every 2 to 3 weeks. 10 in person and 2 by video; none missed. Self-referred after an emergency department visit in April for chest pain, with a normal cardiac workup. Approach: CBT for panic, with psychoeducation, interoceptive exposure, such as spinning in a chair and breathing through a thin straw, and graded exposure from a 12-step hierarchy he wrote. He reached step 8: driving alone for 40 minutes on local roads, and riding the subway at rush hour. Medication: lorazepam 0.5 mg as needed, prescribed by his family physician in April. He has taken none since July, but still carries it.
Panic attacks 3 to 4 times a week since February, with fear of having a heart attack. He had stopped taking the subway, driving on highways, and going to crowded stores, and had missed 2 family visits 2 hours away. DSM-5-TR criteria for panic disorder and agoraphobia were met at intake.
Panic Disorder Severity Scale, PDSS: 17 on June 2, 7 on October 6. PHQ-9: 9 on June 2, 4 on October 6. Panic attacks fell from 3 to 4 a week to 1 limited-symptom attack in the last 4 weeks. He rides the subway to work every day and shops alone. Still to work on: highway driving, flying, which he plans to do in December to visit family, and carrying lorazepam as a safety behavior.
On October 6: mild anticipatory anxiety before new situations, sleeping well, working full time. He denied suicidal thoughts at intake and on October 6, and has no past attempts or self-harm. Drinks 2 or 3 drinks a week; no drug use. No safety plan was needed.
Continue CBT every 2 weeks for 6 to 8 sessions, picking up at step 9 of his hierarchy: highway driving, then a short flight before the December trip. Plan to stop carrying the lorazepam, and to talk with his new family physician if he wants to end the prescription. He has his workbook, hierarchy, and relapse-prevention plan, and will bring them to your first session. I’m glad to talk by phone; his release covers a call.
My session notes, and what Daniel shared in sessions beyond this summary. He can tell you more himself, or sign a further release.
Signed by Hannah Brooks, PsyD, psychologist, with her license number. Sent by secure email to Dr. Lin’s clinic on Monday, October 19, 2026, with a copy to Daniel through the portal, as he asked.
Clinical social worker in a community practice to the client’s family physician, after 8 sessions of IPT
Priya, 33, was referred by her family physician, Dr. Lucia Alvarez, 14 weeks after her son’s birth, with an EPDS of 16 at the clinic. At her eighth session she asked about medication, and agreed that her therapist should write to Dr. Alvarez. She read the letter before it was sent.
Dear Dr. Alvarez, Priya asked me to update you on her therapy, so that you can review her medication options. She signed a release on Tuesday, September 8, 2026, naming you, for coordinating her care. It covers dates, diagnosis, EPDS scores, risk, and recommendations, and ends on September 8, 2027.
8 weekly sessions from Tuesday, September 8, to Tuesday, October 27, 2026, all attended: 5 in person and 3 by video when her son was unwell. Approach: interpersonal therapy, focused on the role change of becoming a parent and on asking for help at home. No medication.
Low mood, tearfulness, guilt about “not enjoying every minute,” and poor sleep even when the baby slept, starting in the third week after the birth. She had stopped seeing friends. Major depressive disorder, single episode, moderate, with peripartum onset, by DSM-5-TR criteria.
EPDS: 17 on September 8, 15 on September 22, 13 on October 6, and 11 on October 27. She walks with a parents’ group twice a week, her partner now does the late feed, and she has told 2 friends how she has been. Still to work on: low mood most mornings, guilt, and worry about her partner going back to work in mid-November, when she will be alone with the baby during the day.
Item 10 of the EPDS scored 1 at intake: passive thoughts that it would be easier not to wake up, with no plan or intent. A safety plan was written that day, and her partner knows it. Item 10 has scored 0 at every session since September 15, and she has denied suicidal thoughts at each one. She has had no thoughts of harming her son at any point. Sleeping 5 to 6 hours a night.
Continue weekly IPT for 4 more sessions, then review. I will repeat the EPDS at each session; if it rises to 13 or more, or item 10 scores above 0, I will call your office the same day. Questions for you: with a partial response after 8 sessions, would medication help? She is breastfeeding and wants to keep going, and safety while breastfeeding is her main worry. She also reports tiredness beyond what night feeds explain; I don’t know whether her thyroid function has been checked since the birth.
My session notes, and what Priya shared in sessions beyond this summary. More can be shared with her further written consent.
Signed by Claire Dubois, MSW, clinical social worker, with her registration number. Sent through the clinic’s secure messaging on Thursday, October 29, 2026. Priya kept a copy.
The client’s written consent comes first. Read it before you write a word: it decides who gets the letter and what goes in it.
Avoid: Sending on a release signed at intake for “coordination of care.” If it doesn’t name this reader and this purpose, ask the client to sign a new one.
The facts of the treatment, so the reader knows how much care stands behind your summary.
Avoid: “Has been in treatment for some time.” Give the dates and the count; a new clinician plans from them.
Why the client came, in a few lines, and the diagnosis only when the client agreed and the reader needs it.
Avoid: A diagnosis in a letter to an employer. Most employers need dates and functional limits, not a label.
What changed, shown with numbers and with daily life. This is the part a new clinician reads twice.
Avoid: “Good progress.” Give the first and latest scores with dates, and say what the client still finds hard.
Where the client is now, and the latest risk assessment with its date, even when it found no risk.
Avoid: Leaving risk out because things are better. The next clinician needs the date of your last assessment and what it found.
What you advise, what you are asking the reader, and what the letter leaves out.
Avoid: Naming a drug for the prescriber to start. Describe the response so far and the client’s questions, and leave the choice to them.
A release signed at intake may not name this reader or this purpose. Check who, what, why, and until when before you send, and ask for a new release if any are missing.
A new therapist needs the work done and what is left. A physician needs the bottom line and your question. An employer needs dates and function. Leave out session content and history that don’t serve the purpose.
“Her trauma history is not included” discloses it anyway. Say that session content isn’t included and that more can be shared with the client’s consent.
“PHQ-9 4” means little alone. Give the first and latest score of each measure, with dates, so the reader can see the change.
Shorthand such as “cog restructuring re: catastrophic misappraisals” loses a family physician. Write plain sentences, and put any question for the reader where they will see it.
Vero Scribe drafts the treatment summary letter in your template from your dictation, or from a session recorded with the client’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Check the client’s written consent first: who it names, what it covers, and when it ends. Then give the treatment dates and number of sessions, the reason for treatment, the approach, progress with first and latest scores, the latest risk assessment, and your recommendations. Keep it to one or two pages, written for the reader, and sign it with your license or registration number.
Who it’s for and why, the client’s consent, the dates of treatment, and as much clinical detail as the reader needs and the consent allows. A new therapist needs the approach, scores, risk, and what is left to work on. A physician needs the bottom line and any question for them. An employer usually needs dates and functional limits only. A court or probation officer asking about attendance needs a treatment attendance letter instead.
Get it in writing before you send. Privacy laws in some places let you share with another treating clinician without it, but ethics codes and clients expect to be asked, and anyone outside the client’s care, such as an employer, needs it. The release should name the reader, what you may share, the purpose, and when it ends.
A termination letter goes to the client and tells them therapy is ending. A termination summary is the closing note in your own record. A treatment summary letter goes to another provider, with consent, and can be sent at any point in therapy, not only at the end.
Yes, with the client’s written consent for that reader. Keep to what they need: that the client is in treatment, the dates, how often, and any functional limits or accommodations. Leave out the diagnosis unless the client agrees and the purpose needs it, as an insurer’s claim often does, and leave session content out entirely.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
A CBT session in its own order: mood check, agenda, homework review, thought or exposure work, new homework, and feedback.
An EMDR session by phase: target, negative and positive cognitions, SUD and VOC, bilateral sets, closure, and reevaluation.
Data, Assessment, Plan: the three-part session note, with the line between facts and judgment made clear.
Goal, Intervention, Response, Plan: a progress note that opens with the treatment plan goal.
Progress notes, summaries, and letters, drafted for your review.
Session notes and letters from your sessions, ready to review.
What totals of 10 and 13 mean, and how to act on item 10.
Score depression symptoms and track change across therapy.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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