TREATMENT 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]