[Today's Date]
1 November 2024
Dr. Eleanor Vance
123 Harley Street
London, SW1A 1AA
Re: Sarah Jones - Referral for Depression
Dear Dr. Vance,
Thank you for referring Sarah Jones to myself at the Lighthouse Psychology Practice, who I met for an initial consultation on 1 November 2024.
Sarah presented with symptoms of low mood, loss of interest in activities, and changes in sleep and appetite. She reported feeling overwhelmed by work and relationship difficulties. During the session, Sarah described feeling hopeless about the future and expressed some passive suicidal ideation. Her history revealed a previous episode of depression five years ago, which was successfully treated with medication and therapy.
Sarah's DASS results indicated severe depression, moderate anxiety, and moderate stress.
Treatment will involve:
- Cognitive Behavioral Therapy (CBT) to address negative thought patterns and behaviours.
- Psychoeducation about depression and coping strategies.
- Weekly individual therapy sessions.
I will write to you at the 6th session to update you on Sarah's assessment, treatment and progress in therapy.
Thank you for referring Sarah for support with us here, at Lighthouse. Should you need to contact me regarding Sarah's psychological care, I am always happy to chat with you.
Sincerely,
Dr. Thomas Kelly
Consultant Psychologist
PY12345
020 7946 0000
[Today's Date]
[Referring Clinician's Name] (Only include if explicitly mentioned in transcript or note, else omit section entirely.)
[Referring Clinician's Practice Address] (Only include if explicitly mentioned in transcript or note, else omit section entirely.)
[City, State, Zip Code] (Only include if explicitly mentioned in transcript or note, else omit section entirely.)
Re: [Patient's Name] - [Reason for referral] (Only include if explicitly mentioned in transcript or note, else omit section entirely.)
Dear [Referring Clinician's Name] (use appropriate title if applicable) (Only include if explicitly mentioned in transcript or note, else omit section entirely.),
Thank you for referring [Client] to myself at the Lighthouse Psychology Practice, who I met for an initial consultation on [date of transcript].
[Provide a brief summary of the healthcare encounter, including the most pertinent findings and information from the session] (Only include if explicitly mentioned in the transcript or note, else omit section entirely. Write in paragraph form, in full sentences.)
[Provide information regarding the DASS results] (Only include if explicitly mentioned in the transcript or note, else omit section entirely. Write in full sentences.)
Treatment will involve:
- [First treatment plan item]
- [Second treatment plan item]
- [Third treatment plan item]
(Only include if explicitly mentioned in the transcript or note, else omit section entirely. Use as many bullet points as needed.)
I will write to you at the 6th session to update you on [Client]'s assessment, treatment and progress in therapy.
Thank you for referring [Client] for support with us here, at Lighthouse. Should you need to contact me regarding [Client]'s psychological care, I am always happy to chat with you.
Sincerely,
[Clinician's Name]
[Qualification]
[Registration Number]
[Contact Details]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)