Functional Status Letter (Psychiatry)

Date: [date of letter]

To: [recipient name, title, organization, full mailing address; use "To Whom It May Concern" only when recipient unknown]

Patient: [full name], DOB [date of birth]

Re: Functional Status and Accommodation Recommendations

Authorization and Clinician Relationship

[Authorization and relationship summary] (Combine: (1) statement that the patient requested this letter and authorized release to the named recipient for the stated purpose; (2) clinician name, credentials, license number and state, and role—e.g., treating psychiatrist vs therapist vs consultant; (3) treatment relationship start date and general nature—e.g., outpatient care, frequency range, and high-level modalities such as medication management and/or psychotherapy. Keep to 3–4 concise sentences.)

Referral Question

[Specific functional question being addressed] (State the concrete functional questions—e.g., accommodations for attendance, concentration, testing conditions, temporary reduced schedule. Note whether a job description/essential requirements or academic accommodation policy was provided and reviewed; if not provided, explicitly state that.)

Clinical Background

[Brief clinical background] (Provide a concise summary of relevant psychiatric diagnoses using DSM terminology—mark as current, in remission, or provisional—or describe clinically significant symptoms if diagnosis disclosure is not required/authorized. Summarize treatment course highlights and current status—e.g., improving/stable/worsening—with functional anchors. Include medication side effects only if they affect functioning. Do not list full medication regimens or detailed psychotherapy content. If no formal diagnosis established, state that symptoms are under evaluation and that functional limitations are based on clinical assessment to date. Keep to one short paragraph.)

Functional Limitations

(Use objective, behaviorally anchored language. Include only domains with meaningful limitations—e.g., concentration/persistence/pace, adaptation/stress tolerance, social interaction, attendance/schedule tolerance, understanding/memory/applying information, sleep–wake stability. For each limitation, document: functional domain, severity, frequency/persistence, and the specific functional consequence. Briefly note the basis for the opinion. Do not infer restrictions for safety-sensitive duties without explicit assessment. Add or remove bullets to reflect only applicable domains.)

• [Functional domain]: [severity level] — [frequency or persistence]. [Specific functional consequence on tasks/activities]. [Basis: e.g., based on clinical interview and longitudinal treatment observations / supported by standardized measure with date and score].
• [Functional domain]: [severity level] — [frequency or persistence]. [Specific functional consequence]. [Basis statement].

Accommodation Recommendations

(List only clinically indicated accommodations linked to limitations documented above. For each, specify whether temporary or ongoing, include expected duration or reassessment date, and acknowledge recipient determines final implementation. Common types include scheduling flexibility, workload/task modifications, environmental adjustments, break allowances, process supports. Add or remove bullets as indicated.)

• [Accommodation] — Addresses [functional limitation]. [Temporary / ongoing]. [Duration: until specific date / for timeframe / cannot estimate, reassessment by date]. Recipient to determine feasible implementation within organizational policies and essential requirements.
• [Accommodation] — Addresses [functional limitation]. [Temporary / ongoing]. [Duration/reassessment plan]. Recipient discretion acknowledged.

Closing

[Brief closing summary] (In 2–3 sentences, reiterate the key functional limitations, core accommodations recommended, and expected duration or reassessment plan. Include a concise disclaimer stating that this letter is based on clinical care and available information, is not a forensic or fitness-for-duty evaluation, and that the recipient determines reasonable accommodations within their policies and the essential requirements of the role.)

Signature

[Signature]

[Printed name, credentials, license type and state]

[Practice address, phone, fax]

[NPI if customary]

(General instructions: Maintain a professional business letter tone. Use objective, behaviorally anchored descriptions of what the patient can and cannot do. Clearly separate factual observations, clinical opinions, and recommendations. Keep total length to 1–2 pages. Omit empty sections. Use explicit "not available" statements only when the missing item materially affects interpretation—e.g., "Job description not provided.")