Return-to-Play Mental Readiness Summary/Letter

Date: [date]

Athlete: [athlete full name, DOB, sport/team]

From: [author name, credentials, organization, contact information]

To: [recipient name, role, organization]

Confidential health information—intended only for the recipient(s) named above.

Authorization & Evaluation Context

[Authorization statement including consent source, authorization date, and purpose (return-to-play coordination). Author's role as [treating clinician / evaluator / consultant], encounter type [in-person / telehealth / hybrid], date range of services, and information sources used.] (3–5 sentences. Include collateral sources only if authorization specifically allows.)

(If authorization is not verified, replace the paragraph above with exactly: "Authorization not verified; unable to release clinical information" and omit all clinical content below.)

Mental Readiness Summary

Current status: [stable / improving / fluctuating / unstable]

[Key functional observations relevant to sport participation, including concentration, emotional regulation, sleep, motivation, and team functioning as applicable] (Summarize in general terms without detailed psychotherapy content or session narratives. Focus on functional readiness for sport.)

Safety screen: [no current risk identified / risk present—describe briefly / not assessed] (Address suicidality, self-harm, substance-related risk, and severe eating disorder indicators. If acute safety concerns are present, note that crisis protocols were activated and this letter does not serve as the intervention.)

Recommendations & Follow-up

Recommended participation level: [full participation / participation with conditions (specify) / limited participation (specify) / not currently recommended for participation]

• Conditions/supports: [specific parameters, restrictions, or accommodations for safe participation] (Include only items necessary for team coordination.)
• Monitoring: [what to monitor, by whom, and how often]
• Reassessment: [timeframe for next review] and [triggers for earlier reassessment: symptom worsening, missed treatment, safety concerns, significant change in role/workload]

Limitations: [Statement noting this summary reflects status as of the date above and mental readiness can change. If author is not the designated clearance authority, state that final return-to-play determination rests with the designated sports medicine authority.]

[Signature]

[Printed name, credentials, license number, NPI if applicable]

[Date signed]