Behavioral Health Clinician-to-Clinician Referral & Care Coordination Letter

Date: [Date of letter]

To: [Recipient name, credentials, organization, secure contact method]

From: [Sender name, credentials, organization, phone, secure fax/email]

Patient: [Name, DOB, MRN if shared system]

Re: [Referral / Consultation / Care Coordination] — [Routine / Time-sensitive / Urgent]

Consent & Disclosure Parameters

[Purpose of disclosure]. [Consent status: obtained / not required for treatment operations / declined / pending] — [Date if obtained]. [Content limitations if any]. (If SUD-related information is included, add redisclosure caution referencing 42 CFR Part 2. If disclosure is limited, briefly state what is intentionally omitted and why. Keep to 2–4 lines.)

Summary & Referral Request

[Executive summary: patient identification (age range, key diagnoses), presenting concern, reason for referral now, current clinical status and trajectory, current risk level]. (Write 3–5 sentences of concise, actionable prose. Label critical information sources.)

• [Specific consultation question or request]
• [Additional question if applicable]
• [Additional question if applicable]

Requested timeframe: [Desired response window]

Preferred feedback method: [Secure message / EHR inbox / phone / fax / secure email]

Clinical Background

Presenting concern & course: [Primary symptoms, onset, duration, severity, functional impact, and trajectory]. (Include only details relevant to the referral question. Label source: patient report / collateral / records / clinician observation.)

Prior treatment & response: [Relevant therapies, levels of care, medications, adherence, and responses; what has helped or not]. (Summarize; avoid exhaustive lists.)

Current diagnoses: [Diagnosis — established / provisional / rule-out]. (Include comorbid medical conditions if relevant to referral.)

Substance use: [High-level summary of substances, patterns, severity, treatment history]. (If disclosure is restricted, provide minimal necessary information consistent with consent. Omit section if not relevant.)

Psychosocial context & functioning: [Housing, relationships, supports, occupational status, stressors, cultural factors, social determinants impacting care]. (Use "Unknown," "Not assessed," or "Patient declined" when applicable.)

Protective factors: [Internal and external strengths and supports relevant to care and safety].

Brief formulation: [Biopsychosocial formulation linking drivers of symptoms to treatment implications]. (Include only if clarifying for the receiving clinician.)

Risk & Safety

Assessment date: [Date and time]

Suicide risk: [Ideation, plan, intent, prior attempts, self-injury; current status and timeframe]. [Relevant protective factors].

Violence risk: [Risk to others, history, current concerns, access to weapons]. (Omit if not relevant.)

Other acute risks: [Grave disability / withdrawal risk / child or elder safety concerns / medical instability]. (Omit if none.)

Lethal means: [Access findings and means-safety steps taken or planned].

Mitigations in place: [Safety plan, crisis resources provided, supportive contacts, monitoring arrangements].

Overall risk judgment: [Low / Moderate / High] — [Brief rationale].

Escalation guidance: [Instructions for the receiving clinician if risk increases, including thresholds and emergency procedures].

(If risk was not assessed, explicitly state the reason and recommend reassessment at intake. If no acute concerns: "No acute safety concerns identified; chronic risk factors include [factors].")

Treatment & Recommendations

Treatment this episode: [Episode dates], [setting and modality], [core interventions], [engagement and adherence], [response and outcomes]. (Exclude psychotherapy session content.)

Current medications: [Medication, dose, frequency, adherence, efficacy, adverse effects]. [Source: patient report / EHR / pharmacy]. (Include only if pertinent to referral.)

Recommendations:

• [Therapy modality and focus]
• [Medication considerations]
• [Level of care and contact frequency]
• [Monitoring needs]
• [Additional referrals or services]

Responsibilities: [What sender will continue vs. what is being transferred].

Please contact me with any questions at [preferred contact method and availability].

Attachments: [Rating scales / discharge summary / medication list / safety plan / none].

Sincerely,

[Typed name, credentials]