Responding to letter requests from clients

Some clients may request that their therapist write a treatment-related letter—often to obtain proof of engagement in therapy, ensure access to gender-affirming medical care, or support an ESA. However, the decision to write a letter for a client has important legal, regulatory, and ethical considerations, as well as potential scope limitations based on your license and professional capacity. 

For example, depending on your license type, it is often out of scope for a therapist to write a letter recommending a Leave of Absence (LOA) from work or school due to mental health symptoms, just as many license types are unable to complete FMLA or disability paperwork for a client. In most cases, only a medical provider is qualified to evaluate and determine the need and duration for an LOA from work or school. 

Before you agree to write any type of treatment related letter for a client, it is best practice to check with your state licensure board and regulatory bodies on what is within scope and to ensure compliance with those standards of practice. These expectations and rules can often vary by state and by license type and are updated periodically, so be sure to stay up-to-date before agreeing to write a treatment-related letter. 

Letter writing best practices

If you decide to write a letter, here are some best practice considerations.

Keep letters brief with only the minimum information necessary

Even at the client’s request—you should never share more than what is necessary to achieve the purpose of the disclosure. Statements in the letter should be factual and congruent with your existing documentation of the client's treatment. For example, check out an example of a simple “treatment summary” letter below that embodies this approach: 

Set an expectation on how long you must work with a client before you will consider writing a letter

A clinical best practice is to set an expectation of boundaries at the start of treatment with your client as it relates to when it would be ethical and appropriate for you to complete a letter request. For example, notifying the client during the initial assessment that there would need to be a minimum of 4 sessions before you could consider writing any letter on their behalf related to their treatment. 

Understand you cannot bill commercial insurance for letter-writing

Any care coordination services (such as the time spent writing letters) are not reimbursable by commercial insurance. You have the option to either conduct this service free of charge or seek self-pay reimbursement from the client. 

To receive reimbursement directly from the client, you would need to negotiate a separate "fee schedule" in writing with the client, where they could pay you directly for those services (it would not be billed through Rula, you would collect payment independently). 

Rula does not offer sample fee schedules, as this is specific to your private practice and license.

Letter Writing FAQ

• Do I need an ROI when I write a letter for a client?
  A release of information is not required when providing letters directly to a client, but it is necessary when sending a letter to a third-party, non-covered entity. 
  
  
• If I determine that I am not able to provide a letter to my client, what other options can I give them?
  The client could request their medical records from Rula that denote their diagnosis and symptoms and do what they wish with those records, including providing it to 3rd parties. Also, many letters are more appropriately handled by a primary care medical doctor or a psychiatrist. Encouraging your client to pursue their letter needs from another professional is often an appropriate route to explore.
  
  
• Based on my assessment, I do think my client could be appropriate for a Leave of Absence (LOA) from work due to the severity of their mental health symptoms. If it is not within my scope to write a letter recommending or approving this, what can I do to advocate for my client? 
  
  

First, you should ensure the progress notes you complete clearly state:

• • client's specific symptoms
  • level of symptom severity 
  • and marked functional impairment 

Next, you should:

• • Engage in a collaborative, informed discussion with the client on whether or not a referral to a medical provider for a LOA assessment and recommendation is warranted. 
  • Emphasize that it is up to the medical provider's discretion whether or not to provide an LOA, and providers typically like to see patients multiple times before sending an LOA. Additionally, some providers will not be willing to write LOA’s for patients who are not interested in medication as part of their mental health treatment.
  • You may also choose to write a brief treatment summary letter that does not include any specific recommendations for LOA (if not within scope per your license) but instead focuses on factual clinical information that aligns with your existing documentation of the client's treatment, and that might support a provider's evaluation. You can provide this letter directly to the client to use at their discretion. 

• Does Rula have any templates I can use to write a letter?
  No. Because each Rula therapist is an independent private practice therapist with variable scopes of practice and each client has individualized, unique needs within these requests, Rula does not provide any letter templates. However, you can always consult with our Clinical Quality team to write letters.

As always, you can contact quality@rula.com directly if you have additional questions or support needs related to writing letters for clients. Therapist to therapist—we’re here for you!