Referral/Consult Letter (Grief Counseling)

Date: [date written; include time if urgent]

To: [recipient name, credentials, specialty, clinic, phone/fax]

From: [author name, credentials, role, clinic, phone, secure email]

Re: [patient full name, DOB, MRN]

Consent/ROI: [ROI on file dated ____ / Shared for treatment purposes; psychotherapy notes excluded]

Attachments: [list any attached scales, labs, or documents with dates] (Omit this line if none)

Confidential clinical communication for treatment purposes.

Reason for Referral

[Referral summary stating: relationship to patient and role; referral type (consultation only / co-management / transfer of care); 1–3 specific consult questions; urgency level (routine / semi-urgent / urgent) with rationale; expected response timeframe if urgent] (Write as 3–6 sentences that allow the recipient to understand the purpose without reading further.)

Grief & Clinical Context

• Loss details: [who died or what was lost; relationship significance; date and time since loss; circumstances—expected vs sudden/traumatic, witnessed, pending legal matters] (If unknown, state "Unknown—patient unable/unwilling to discuss.")
• Cultural/spiritual context: [relevant beliefs, practices, community context] (Include only if applicable.)
• Current symptoms: [dominant clusters present: grief yearning/preoccupation, mood, anxiety, trauma, sleep/appetite/energy, substance use changes] (Summarize without enumerating every symptom.)
• Functional impact: [specific observable impairments: work/school attendance, ADLs, caregiving, social withdrawal]
• Current treatment: [start date, frequency, modality/approach, response to date, existing coordination]
• Clinical impression: [working diagnosis or differential—grief vs MDD vs PTSD vs adjustment disorder; note if prolonged grief disorder suspected and whether duration/criteria assessed]
• Standardized measures: [instrument names with scores and dates, e.g., PHQ-9, GAD-7, PCL-5, grief-specific scales] (Omit if none available.)

Risk & Safety Assessment

• Suicidal ideation: [present / absent / not assessed] (If present, include frequency, plan, intent, preparatory behaviors.)
• Past suicidal behavior: [none / self-harm history / prior attempts with dates and methods / not assessed]
• Access to lethal means: [firearms / medications / other / none known / not assessed] (Include mitigation steps in place.)
• Homicidal ideation: [present / absent / not assessed] (Include only if clinically indicated.)
• Protective factors: [supports, beliefs, future orientation, treatment alliance, reasons for living]
• Overall risk level: [low / moderate / high] (Provide brief justification.)
• Safety plan status: [completed on date / in progress / not completed; crisis resources provided; patient's stated willingness to use them]
• Escalation plan: [steps if risk worsens, emergency contacts, after-hours coverage]

Relevant Background

• Psychiatric history: [prior diagnoses, hospitalizations, treatments and responses] (Include only items pertinent to the consult question.)
• Current medications: [medication names with doses] (If incomplete for medication consult, state "Medication list incomplete—to be obtained.")
• Allergies: [NKDA / specific allergies / unknown]
• Medical conditions: [conditions relevant to mental health treatment] (Include only pertinent items.)
• Psychosocial factors: [living situation, supports, stressors, access barriers]

Requested Actions

1. [Actionable request 1, e.g., diagnostic clarification: PGD vs MDD vs PTSD]
2. [Actionable request 2, e.g., medication recommendations with relevant constraints]
3. [Actionable request 3, e.g., modality/level of care guidance]

(Include 1–5 numbered requests; each should be specific and tied to a change in care.)

Interim plan while awaiting consult: [follow-up schedule, monitoring plan, patient instructions if symptoms worsen, escalation steps if risk elevated]

Closing

Thank you for reviewing this referral. Please contact me with any questions or recommendations.

Signature:
[Author name, credentials]
[Role/title, clinic/organization]
[Direct phone, secure email, fax]
[Best contact times]
[Supervising clinician name, credentials, and co-signature line] (Include only if trainee.)