Referral Letter (Higher Level of Care)

Referral Letter for Higher Level of Psychiatric/Addiction Care

(Professional letter style; assume the recipient has no EHR access. Use explicit calendar dates rather than relative terms. Prefer omission for non-critical unknowns; for safety-critical unknowns, state "unknown" or "not assessed" with brief explanation. Avoid dangerous abbreviations; include clear dose units and routes.)

Date: [date of letter]

Patient: [full name], DOB [date of birth], MRN [if available]

Current Location: [home / clinic / ED / inpatient unit] | Contact: [phone]

Referring Clinician: [name, credentials, role] | Callback: [direct phone] | Organization: [clinic/practice name]

Recipient Program: [facility/program name, level of care] | Contact: [fax / phone / secure message]

Release of Information: [status, date, and scope of signed release; note if SUD information is included and consent status is uncertain]

Dear [Admissions/Intake Team or specific contact name],

Reason for Referral

[Executive synopsis: requested service and level of care, urgency/time frame, primary clinical drivers necessitating step-up, brief current risk statement, and why current supports are insufficient] (Write 4–6 concise sentences specifying the exact service requested, the timeframe, the core clinical drivers, a brief current risk statement, and why current supports and setting are insufficient.)

[Precipitating events and timeline] (Summarize events over the past days to weeks: what changed, what was tried at the current level of care, and why the current setting failed or became unsafe.)

Clinical Background

Diagnoses: [active diagnoses driving referral, then relevant comorbidities with severity specifiers and status] (List primary psychiatric diagnoses first, followed by substance use disorders if applicable, then medical conditions impacting placement or safety.)

Relevant History: [pertinent psychiatric history, substance use history if applicable, and medical conditions affecting placement] (Include prior hospitalizations, suicide attempts, psychosis/mania episodes, substances used with last use date, withdrawal history including seizures/DTs, overdose history, and medical conditions affecting detox or sedation safety. Include only what is relevant to placement needs.)

Current Treatment & Medications: [current psychiatric medications with dose/route/frequency, MAT details if applicable, recent changes, adherence concerns, allergies with reaction type, current treatment engagement and barriers] (For MAT, include agent, dose, last administered date/time, and induction/maintenance status.)

Psychosocial Context: [housing stability, support system, transportation access, legal involvement, lethal means access, language needs] (Include factors relevant to risk or placement matching.)

Pertinent Objective Findings: [relevant vitals, mental status exam highlights, withdrawal severity scores with date/time, relevant labs or toxicology with dates] (Include only findings that support the referral. If objective data were not obtained, state this briefly.)

Risk Assessment

Suicide/Self-Harm Risk: [current ideation, plan/intent, access to means, recent attempts or self-injury, protective factors] (Include one brief direct quote only if it conveys critical intent or plan.)

Violence Risk: [homicidal ideation, identified targets, access to weapons, recent threats or behaviors] (Include only if applicable.)

SUD-Specific Risks: [overdose risk factors, withdrawal complication risk, ability to maintain safe environment during withdrawal] (Include for SUD referrals.)

Overall Risk Impression: [one-sentence summary linking current risk presentation to need for higher level of care]

Assessment & Plan

Clinical Formulation: [2–3 sentence formulation linking symptoms, diagnoses, risk factors, and functional impairment to explain why step-up is necessary]

Level-of-Care Justification: [why higher level is needed, why current or lower level is insufficient, why timing is now] (Address severity/acuity/monitoring needs, failed outpatient or inability to maintain safety, and imminent risk or worsening trajectory.)

ASAM Dimensional Considerations: [brief summary of relevant ASAM dimensions] (For SUD referrals only; address succinctly: D1 withdrawal potential, D2 biomedical risk, D3 cognitive/emotional complications, D4 readiness, D5 relapse potential, D6 recovery environment. Omit if not applicable.)

Receiving Program Requirements: [required medical monitoring level, co-occurring psychiatric capability, MAT continuation or induction needs, trauma-informed care, language access, other accommodations critical to safety or efficacy]

Interim Care Pending Acceptance: [safety measures in place, medication bridge plan, crisis instructions provided, contingency plan if symptoms escalate before transfer]

Disposition: [current location, transport plan with estimated timing, items sent with referral such as medication list, safety plan, naloxone, ROI documents]

Thank you for your prompt review and assistance in coordinating care at the requested level.

[Signature: name, credentials, NPI if applicable, date/time]

[Direct callback and secure contact method]

[Verbal handoff status: completed or requested, with preferred contact windows]