Letter Template:
For use by a psychiatrist seeing a patient for the first time or for a longer appointment, this NovoNote template provides a structure for a detailed formal letter to be forwarded to the referrer (GP) following an initial clinical interview and assessment appointment. It includes information captured by the Psychiatric Clinical Interview and Assessment template, and converts this information into a structured, clinically appropriate letter.
In Australia, it would be suitable to use under MBS Item 291, and other MBS Item Numbers for longer appointments.
Note: For letters relating to previously seen patients, it is recommended that other templates with less background information be used, such as the Psychiatrist Letter to Referrer – General Review Appointments template.
Dr Referring Clinician’s Name
Referring Clinician’s Address
Re: Patient name, DOB Patient date of birth, Patient address
Dear Referring Clinician’s Name,
Thank you for referring Patient’s Name for a psychiatric assessment.
Provide a brief summary of the presenting problem or purpose of the appointment, including type and nature of symptoms, length of time with symptoms, external stressors, interpersonal or relationship factors, and impact on functioning.
Personal and Developmental History:
- Summarise patient’s personal and developmental history including early development, family history and structure, education and employment history, occupation, current living arrangements, and social support
- Describe any history of trauma, including family or intergenerational trauma, or significant adversity
- Describe family history of illness or medical conditions, including psychiatric illness and neurodevelopmental conditions, family suicides, or addiction behaviours
Current Key Lifestyle Indicators:
- Provide detailed summary of patient’s current key lifestyle indicators relevant to presenting concerns
- Describe current sleep pattern and sleep hygiene
- Describe current diet, including binge behaviours, caffeine intake, and junk food consumption
- Describe current level of physical exercise or general activity levels
- Describe level of social functioning, including quality and quantity of relationships and extent of social isolation
Medical Status and Medical History:
- List previous non-psychiatric diagnoses and medical conditions, including when diagnosed and by whom
- Provide information about responses to treatment, effective outcomes, side effects, and adverse reactions
Psychiatric Illness History:
- List previous psychiatric diagnoses and conditions, including when diagnosed and by whom
- Describe responses to treatment, effective outcomes, side effects, and adverse reactions
- Describe previous psychological interventions and past hospitalisations for mental health reasons
Medication History:
- List all current medications, including psychotropic and non-psychotropic, with doses and frequencies
- Describe medication history including response to past medications, side effects, adverse reactions, and adherence
Drug and Alcohol Use History:
- Provide detailed summary of drug and alcohol use history
- Describe current level of alcohol consumption, cigarette or vape use, and other recreational or illicit substance use
- Describe any past or current misuse of prescription medications
Other Addiction History:
- Provide detailed summary of other addiction history
- Describe any other potentially problematic addictive behaviours, even if patient does not view as problematic
Legal and Forensic History:
- Provide detailed summary of legal and forensic history
- Describe any previous history involving illegal activity, justice system interactions, imprisonment, family law interactions, or domestic violence behaviour
Mental Status Examination (MSE):
- Appearance: Describe the patient’s general physical appearance, hygiene, grooming, and attire
- Behaviour: Describe the patient’s interaction with surroundings, activity level, psychomotor activity, eye contact, and rapport
- Speech: Describe the rate, volume, tone, coherence, and articulation of the patient’s speech
- Mood and Affect: Describe the patient’s reported mood and emotional state, range and appropriateness of emotional response, and any discrepancies
- Thought Process: Describe the patient’s coherence, organisation, and flow of thoughts
- Thought Content: Describe the content of thoughts, noting presence of delusions, distortions, obsessions, or intrusive thoughts
- Perception: Describe hallucinations or other perceptual disturbances
- Cognition: Describe orientation to time/place/person, attention, memory, concentration, and comprehension
- Insight and Judgment: Describe understanding of mental health condition and decision-making capacity
Strengths, Coping Skills, Recreational Interests, and Hobbies:
- Provide detailed summary of patient’s strengths, positive coping skills, recreational interests, hobbies, and protective factors that are helpful for managing mental health
Psychometric Testing:
- For each psychometric test, include: name of assessment, brief description, date of administration, and relevant purpose
- Provide summary of quantitative results and interpretation
- Provide implications of results in clinical context
- Detail any plans for future psychometric testing
Formulation / Impression:
- Provide detailed bio-psycho-social psychiatric formulation, including predisposing, precipitating, perpetuating and protective factors
- Include psychodynamic formulation if applicable
- Include evidence from assessment to enhance formulation details
Diagnosis:
- Describe diagnostic impressions based on DSM-5-TR and ICD-11 criteria
- Include diagnostic codes
- Specify if diagnoses are new or confirmation of previous diagnoses
- Detail any comorbidities or differential diagnosis considerations
Risk:
- Make risk assessment statement regarding suicidal or homicidal ideation, self-harm or harm to others, and risk of relapse
- Include information about past suicide attempts or self-harming behaviour
- Include psychosocial stressors contributing to risk level
- Include protective factors that mitigate risk
Treatment Plan Discussed With Patient:
- Specify evidence-based recommendations for medication changes and rationale
- Specify suggested non-pharmacological interventions and rationale
- Specify referrals to other specialists or services and rationale
- Detail plan for follow-up and monitoring
- Detail any Safety Plan made in event of risk to safety
- Summarise education provided about diagnosis and treatment options
- Summarise other recommendations made specifically to the General Practitioner
Summary:
- Provide brief paragraph summary of the appointment
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Psychiatrist Name
Dr James Jones
NovoPsych Medical Centre
1 Station Road
Carlton VIC 3053
Re: Mary Blogs, DOB 15/08/1985, 1 NovoNote Street, Parkville VIC 3052
Dear Dr Jones,
Thank you for referring Mary Blogs for a psychiatric assessment.
Mary presents with a three-month history of persistent low mood, anxiety, and sleep disturbance following the breakdown of her marriage and subsequent divorce proceedings. She reports significant anhedonia, social withdrawal, and difficulty concentrating at work as a primary school teacher, with symptoms intensifying during custody negotiations regarding her two young children. Mary describes feeling overwhelmed by single parenting responsibilities while managing her teaching workload, leading to decreased performance and concerns from her school principal about her wellbeing.
Personal and Developmental History:
Mary grew up in a stable two-parent household as the eldest of three children, achieving well academically and completing a Bachelor of Education before marrying at age 25. She has two children aged 6 and 8 years and currently lives in the former family home with limited financial support from her ex-husband. Significant childhood trauma includes witnessing domestic violence between her parents from age 8-12, with her father’s alcoholism and verbal aggression toward her mother before her parents divorced when she was 13. Mary reports taking on a caretaking role for her younger siblings during this period and feeling responsible for her mother’s emotional wellbeing. Family history is notable for maternal depression requiring hospitalisation when Mary was 15, and paternal history of alcohol use disorder.
Current Key Lifestyle Indicators:
Mary’s sleep pattern is severely disrupted with difficulty falling asleep until 2-3 AM and early morning waking at 4 AM, resulting in only 3-4 hours sleep nightly. Her diet consists mainly of convenience foods with frequent meal skipping, increased caffeine intake of 4-5 cups coffee daily, and occasional binge eating episodes. Physical exercise has ceased completely since the marriage breakdown, though she previously walked regularly for stress management. Social functioning is significantly impaired with complete withdrawal from friendships and family relationships, avoiding social situations and declining invitations from previously close friends.
Medical Status and Medical History:
No significant medical conditions reported aside from recurrent headaches since onset of current episode. Mary currently takes no regular medications though reports frequent use of over-the-counter pain medication for headaches.
Psychiatric Illness History:
No previous psychiatric diagnoses or formal treatment. Brief episodes of anxiety during university exams and again during her mother’s hospitalisation but did not seek professional help. Reports period of low mood lasting several months following birth of second child but attributed this to normal adjustment difficulties.
Medication History:
No current or previous psychotropic medications. Occasional use of paracetamol and ibuprofen for headaches with good response and no adverse effects reported.
Drug and Alcohol Use History:
Alcohol consumption has increased to 2-3 glasses of wine nightly since separation, occasionally up to a full bottle on weekends. No tobacco use or illicit substance use reported, though Mary acknowledges concern about her current drinking pattern and its potential impact on her mood and sleep.
Mental Status Examination (MSE):
- Appearance: Well-groomed woman appearing tired with dark circles under eyes and noticeable weight loss
- Behaviour: Cooperative but frequently tearful during interview, maintained appropriate eye contact though became agitated when discussing custody arrangements
- Speech: Normal rate and volume with occasional tremor in voice when discussing children
- Mood and Affect: Self-described mood as “devastated and hopeless,” with affect congruent and depressed, episodes of anxiety when discussing future
- Thought Process: Generally coherent and goal-directed with some rumination about marriage failure and self-blame
- Thought Content: Preoccupied with divorce proceedings and children’s wellbeing, themes of personal failure and inadequacy, no delusions but catastrophic thinking about future
- Perception: No hallucinations or perceptual disturbances reported
- Cognition: Fully oriented with some impairment in concentration and working memory, particularly when anxious
- Insight and Judgment: Good insight into current difficulties and recognises need for help, judgment generally intact though some impaired decision-making regarding alcohol use
Strengths, Coping Skills, Recreational Interests, and Hobbies:
Mary demonstrates strong dedication to her children’s wellbeing and maintains their routines despite personal distress. She previously enjoyed reading historical fiction and gardening before the current episode and shows good problem-solving skills in her professional teaching role. Mary has a strong work ethic and commitment to education, respected by colleagues and parents, and demonstrates resilience through her ability to continue working despite significant emotional difficulties.
Formulation / Impression:
Mary’s presentation represents a major depressive episode with anxiety features precipitated by marital breakdown and divorce proceedings. Predisposing factors include childhood exposure to domestic violence and parental mental illness, creating vulnerability to relationship trauma and tendency toward self-blame. Her history of taking on caretaking roles from an early age contributes to current feelings of failure when unable to maintain her marriage. Precipitating factors include her husband’s departure and ongoing legal stress. Perpetuating factors include social isolation, disrupted sleep, increased alcohol use, and rumination about personal inadequacy. Protective factors include her commitment to her children, stable employment, and good insight into her difficulties.
Diagnosis:
Major Depressive Disorder, single episode, moderate severity (DSM-5-TR: 296.22, ICD-11: 6A70.1). Secondary diagnosis of Alcohol Use Disorder, mild severity (DSM-5-TR: 303.90, ICD-11: 6C40.0) – emerging pattern requiring monitoring. These are new diagnoses with no previous psychiatric history.
Risk:
Mary denies current suicidal ideation but reports passive thoughts that “everyone would be better off without me” and occasional fleeting thoughts of driving into oncoming traffic, though she states she would never act on these due to her children. No history of suicide attempts or deliberate self-harm behaviours. Current high-risk factors include ongoing custody stress, financial pressures, social isolation, and increased alcohol use. Protective factors include strong maternal bond with her children, maintaining employment, and seeking help voluntarily.
Treatment Plan Discussed With Patient:
Commence sertraline 50mg daily with plan to review in two weeks and titrate to 100mg as needed, with discussion of common side effects and importance of adherence. Referral to psychologist specialising in trauma and depression for cognitive behavioural therapy focusing on processing childhood trauma and current adjustment difficulties. Recommendation for GP review to assess physical health, address headaches, and monitor alcohol consumption with brief intervention. Follow-up appointment scheduled in two weeks to monitor medication response and symptom improvement. Safety planning discussed with instruction to contact crisis services if thoughts of self-harm emerge. Recommend monitoring alcohol consumption and providing brief intervention for emerging alcohol use concerns.
Summary:
Mary presents with major depressive disorder triggered by marital breakdown, with underlying vulnerability related to childhood trauma exposure and emerging alcohol use concerns. She demonstrates good insight and motivation for treatment despite significant current distress. Comprehensive treatment plan includes antidepressant medication, psychological therapy, and close monitoring of risk factors.
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Sarah Smith
- Template Type
- Letter
- Report
- Note Dictation
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