Do I need the client's written consent before writing to their PCP?

Yes. Under HIPAA, sharing clinical information with another provider for treatment purposes is permitted under the Treatment, Payment, and Healthcare Operations (TPO) exception, so a formal authorization may not be legally required in all cases. However, best practice — and many state laws and ethical codes — call for discussing the communication with the client and obtaining their informed consent before sending clinical information to their PCP. Document the consent in the clinical record. Some clients may not want certain information shared (for example, substance use history or specific diagnoses), and their preferences should be respected.

What should I include about medication if I am not a prescriber?

You should not prescribe or make specific medication recommendations — that is outside the scope of a non-prescribing therapist's practice. However, you can share clinically relevant observations that may inform the PCP's prescribing decisions: symptom severity and trajectory (using standardized measures), functional impairment, the client's reported response to current medications, side effects the client has reported, and whether the client has expressed interest in a medication evaluation. Frame these as clinical observations rather than prescribing recommendations.

How often should I send updates to my client's PCP?

There is no universal standard, but common practices include: an initial letter at the beginning of treatment to inform the PCP that their patient is receiving mental health care, updates when there is a clinically significant change (medication considerations, diagnostic clarification, safety concerns, functional improvement or decline), and a discharge summary when treatment ends. For clients on psychotropic medications prescribed by their PCP, more frequent communication — perhaps quarterly — may be clinically appropriate. Always ask the PCP about their preferred communication frequency and format.

What if the client's PCP is prescribing a psychotropic medication and I have concerns about it?

If you have clinical observations that are relevant to the PCP's prescribing — such as the client reporting worsening symptoms, side effects, or non-adherence — share these observations in a letter or phone call (with the client's consent). Frame your communication as sharing clinical data rather than critiquing the prescribing decision. For example, instead of writing 'the current medication does not appear to be working,' write 'the client's PHQ-9 score has increased from 12 to 18 over the past eight weeks, and the client reports persistent insomnia and low motivation.' Let the PCP use this clinical data to inform their medical decision-making.

Should I send a letter to the PCP even if the client does not have mental health medication considerations?

Yes, PCP communication is valuable even without medication involvement. Mental health conditions affect physical health, medical treatment adherence, and overall functioning. Informing the PCP that their patient is in mental health treatment helps the PCP understand the full clinical picture, screen for somatic symptoms that may be related to mental health conditions, consider mental health factors when treating physical complaints, and provide coordinated care. A brief initial letter and occasional updates support the integrated care model that produces the best outcomes.

Letter to Primary Care Physician from Therapist: Template & Guide

Clinical Letters|13 min read|Updated 2026-03-20|Clinically reviewed

What Is a Letter to a Primary Care Physician?

A letter to a primary care physician (PCP) from a therapist is a clinical communication that facilitates coordinated care between a client's mental health provider and their medical provider. It informs the PCP about the client's mental health treatment, shares clinically relevant information that may affect medical care, and supports the collaborative management of the client's overall health.

This type of letter serves the integrated care model, which recognizes that mental and physical health are interconnected and that providers achieve better outcomes when they communicate. For many clients, the PCP is the first point of contact for health care and may be the provider managing psychotropic medications, monitoring physical health effects of mental health conditions, or addressing somatic symptoms that overlap with psychological presentations. When the therapist and the PCP are not in communication, gaps in care emerge — medications are prescribed without behavioral health context, physical symptoms related to mental health go unrecognized, and treatment plans work at cross purposes.

The letter is a professional peer-to-peer communication. It should be written in clinical language that a medical provider can efficiently read and act on. PCPs are time-constrained and receive high volumes of correspondence. An effective letter is concise, organized, clinically relevant, and clearly identifies any action items or requests.

When You Need It

When beginning treatment with a new client, to inform the PCP that the client is receiving mental health care
When the client's clinical presentation suggests a need for medication evaluation or adjustment, and the PCP is the prescribing provider
When you observe symptoms that may have a medical component — such as fatigue, sleep disruption, appetite changes, or cognitive impairment — that the PCP should evaluate
When the client's mental health treatment progress is relevant to medical treatment decisions the PCP is making
When the client is on psychotropic medications prescribed by the PCP, and your clinical observations can inform ongoing medication management
When terminating treatment, to provide the PCP with a summary and recommendations for ongoing care
When there are safety concerns that the PCP should be aware of, such as suicidal ideation or significant self-harm

Key Components

Your credentials and contact information. State your name, degree, license type, license number, NPI, practice name, and contact information. Include your phone and fax numbers so the PCP can respond or consult easily.

Client identifying information. Full name, date of birth, and any shared medical record number or insurance ID that helps the PCP match the correspondence to the correct patient.

Purpose of the letter. State clearly why you are writing — whether it is an initial notification, a clinical update, a medication-related communication, or a discharge summary. The PCP should know within the first two sentences what this letter is about and what, if anything, you are asking them to do.

Diagnostic impression. Share your diagnostic formulation. PCPs work with ICD-10 codes routinely and will find a clear diagnostic summary useful. Include comorbid conditions if relevant to medical care.

Current clinical status. Describe the client's current symptom severity, functional level, and treatment progress. Use standardized measure scores (PHQ-9, GAD-7, PCL-5, etc.) when available — medical providers are familiar with these instruments and find them efficient to interpret.

Treatment summary. Briefly describe the type of therapy being provided, the frequency, the treatment approach, and the goals. The PCP does not need a detailed treatment plan, but understanding what the client is working on in therapy helps them provide coordinated care.

Medication-relevant observations. If the PCP is prescribing psychotropic medication, share observations that inform medication management — reported side effects, symptom response or non-response, adherence concerns, and standardized measure trends. If the client is not on medication and you believe an evaluation is warranted, state this clearly.

Specific requests or recommendations. If you are requesting something specific from the PCP — such as a medication evaluation, lab work, or a referral — state it explicitly. If you have no specific request and are simply providing information, say that.

Letter to PCP — Depression Treatment Update and Medication Considerations

[Practice Letterhead]

March 20, 2026

Dr. Michelle A. Okonkwo, MD Riverside Family Medicine 2100 Riverside Drive, Suite 140 Columbus, OH 43221 Fax: (614) 555-0384

Re: Clinical Update — Mental Health Treatment Patient: Brian T. Castillo Date of Birth: 12/05/1980 Insurance ID: UHC-449827103

Dear Dr. Okonkwo,

I am writing to update you on the mental health treatment of our shared patient, Brian Castillo, and to share clinical observations that may be relevant to his ongoing medical care.

Provider Information: Name: Dr. Anil R. Kapoor, PsyD License: Licensed Clinical Psychologist, #PSY.6784 (OH) NPI: 1234509876 Practice: Clintonville Psychological Services Address: 3567 North High Street, Suite 200, Columbus, OH 43214 Phone: (614) 555-0271 Fax: (614) 555-0272

Clinical Relationship: Mr. Castillo has been receiving individual psychotherapy in my practice since October 2025. I see him weekly. This letter is sent with Mr. Castillo's written consent.

Diagnostic Impression:

Major Depressive Disorder, recurrent episode, moderate (F33.1)
Generalized Anxiety Disorder (F41.1)

Clinical History: Mr. Castillo self-referred for therapy in October 2025 following a recurrent depressive episode that began approximately three months prior. He reports a history of two prior depressive episodes (ages 28 and 37), both of which resolved with psychotherapy alone. His current episode has been more persistent and severe than previous episodes, and he describes it as the worst depression he has experienced. Precipitating factors include a job loss in June 2025 and subsequent financial strain.

Current Clinical Status: Mr. Castillo has been in treatment for approximately five months. He has attended 20 sessions of cognitive-behavioral therapy. While he has made some progress, his response to psychotherapy alone has been slower than expected, and he continues to experience clinically significant symptoms:

PHQ-9 scores: 19 (intake, October 2025) → 17 (December 2025) → 15 (current, March 2026). He remains in the moderately severe range.
GAD-7 scores: 14 (intake) → 11 (current). He has moved from the severe to the moderate range.
Sleep: He reports persistent insomnia with difficulty both initiating and maintaining sleep. He estimates 4 to 5 hours of fragmented sleep per night despite implementing sleep hygiene strategies. Sleep disruption is one of his most distressing symptoms and is contributing to daytime fatigue, impaired concentration, and irritability.
Appetite and weight: He reports a loss of appetite and has lost approximately 15 pounds since July 2025. He describes eating one meal per day on most days.
Concentration: He reports significant difficulty with sustained attention, reading comprehension, and decision-making. He describes this as "brain fog" and notes that it is affecting his job search and daily task management.
Anhedonia: Persistent loss of interest in activities he previously enjoyed, including exercise, cooking, and social gatherings. He reports feeling "flat" most of the time.
Suicidal ideation: He reported passive suicidal ideation ("I sometimes think it would be easier if I didn't wake up") during sessions 6 through 12. He denied any plan, intent, or access to means. Passive ideation has not been reported in the past two months, but I continue to assess at each session.

Treatment Progress: Mr. Castillo is engaged and motivated in therapy. He consistently attends sessions, completes between-session assignments, and is actively learning and applying cognitive-behavioral skills. His anxiety symptoms have shown a clearer response to CBT than his depressive symptoms. He has developed effective strategies for managing worry and has reduced avoidance behaviors in several areas. However, his core depressive symptoms — particularly sleep disruption, anhedonia, appetite loss, and concentration impairment — have been resistant to psychotherapy alone. His PHQ-9 has decreased only four points over five months of weekly CBT, which is a slower trajectory than expected.

Medication-Relevant Observations: I am sharing the following observations for your consideration in evaluating whether psychopharmacological intervention may be appropriate for Mr. Castillo:

His depressive symptoms — particularly the neurovegetative symptoms of insomnia, appetite loss, and concentration impairment — have shown limited response to five months of weekly CBT. Research supports that moderate-to-severe MDD with prominent neurovegetative features often responds better to combined psychotherapy and pharmacotherapy than to psychotherapy alone.
This is his most severe depressive episode, and the two prior episodes that resolved with therapy alone were reportedly milder (he describes them as "feeling down for a few months" compared to the current episode).
His sleep disruption is particularly severe and is contributing to a cascade of functional impairment. He has implemented sleep hygiene, stimulus control, and sleep restriction strategies with minimal improvement, suggesting that the insomnia may be more biologically driven than behaviorally maintained.
Mr. Castillo has expressed interest in exploring medication. He had previously been reluctant but has initiated this conversation in recent sessions, noting that he feels he is "doing everything right in therapy" but not improving as much as he expected.

I want to be clear that I am sharing these clinical observations to support your medical decision-making, not recommending a specific medication or dosage. If you determine that a medication evaluation is appropriate, I am happy to coordinate with you regarding his ongoing treatment.

Other Medical Considerations: Mr. Castillo has reported the following symptoms that may warrant medical evaluation if they have not already been assessed: persistent fatigue that does not improve with rest, a 15-pound unintentional weight loss over approximately eight months, and intermittent headaches (2 to 3 times per week) that he attributes to poor sleep. While these may be fully accounted for by his depressive episode, ruling out contributing medical factors could be valuable.

Request: I would appreciate it if you could consider the following:

Whether a psychopharmacological evaluation for Mr. Castillo's depressive symptoms is clinically appropriate
Whether any medical workup (such as thyroid function, CBC, or metabolic panel) is indicated given his reported symptoms

I am available for a phone consultation if that would be helpful. Please feel free to contact me at the number above.

Sincerely,

Dr. Anil R. Kapoor, PsyD Licensed Clinical Psychologist Ohio License #PSY.6784

This is a sample for educational purposes only — not real patient data.

How to Write It Step by Step

Step 1: Obtain the client's consent. Discuss with the client that you would like to communicate with their PCP, explain why, and review what information you plan to share. Obtain written consent and document it. Some clients may want to exclude certain information — respect those preferences.

Step 2: Identify the purpose of the letter. Before writing, clarify what you want to accomplish. Are you introducing yourself as the client's therapist? Sharing a clinical update? Raising a medication concern? Requesting a medical evaluation? The purpose determines the content, length, and tone.

Step 3: Address the letter to the specific provider. Use the PCP's name, credentials, and practice address. Generic letters addressed to "To Whom It May Concern" suggest the communication is an afterthought rather than a purposeful clinical correspondence. Include the fax number — many medical offices route clinical correspondence through fax.

Step 4: Lead with the purpose and patient identifiers. The PCP should know within the first sentences who the patient is and why you are writing. Medical providers process high volumes of correspondence and will triage your letter based on the opening. State the patient's name, date of birth, and your reason for writing immediately.

Step 5: Use clinical language the PCP will recognize. Write in the language of clinical medicine, not therapy jargon. Use ICD-10 codes, standardized measure scores, and medical terminology. PCPs are fluent in clinical shorthand — PHQ-9 of 15, sleep onset latency of 90 minutes, BMI change — and this language communicates efficiently.

Step 6: Present data, then interpretation. Share the objective clinical data first — measure scores, symptom frequency, behavioral observations — then your clinical interpretation. This allows the PCP to form their own impressions before reading yours, which is how medical providers are trained to process information.

Step 7: Make specific requests clearly. If you are asking the PCP to do something — evaluate for medication, order labs, adjust a prescription — say so explicitly in a clearly labeled section. Do not bury requests in the middle of a paragraph. If you have no specific request, state that the letter is for informational purposes.

Step 8: Keep it to one to two pages. PCPs will not read a five-page letter. Be comprehensive but concise. Include the information that is relevant to the PCP's care of the patient and leave out therapy session details, treatment plan minutiae, and background information that does not affect medical decision-making.

Common Mistakes

Writing in therapy language rather than medical language. A letter that discusses "core beliefs," "attachment patterns," or "inner child work" will not communicate effectively to a PCP. Translate your clinical observations into medical terminology: symptom severity, functional impairment, diagnostic impressions, and standardized measure trajectories.
Making prescribing recommendations. If you are not a prescriber, do not recommend specific medications, dosages, or medication changes. Share clinical observations that inform prescribing decisions and let the PCP apply their medical expertise. Overstepping this boundary damages the collaborative relationship and may violate scope of practice regulations.
Sending generic letters. A letter that says "your patient is in therapy with me and doing fine" provides no useful clinical information. If you are going to write, include data that actually informs the PCP's care of the patient.
Failing to include standardized measure scores. PCPs are trained in data-driven decision-making. A PHQ-9 trajectory from 19 to 15 over five months communicates far more efficiently than two paragraphs describing the client's mood. Include the numbers.
Not including contact information or fax number. If the PCP wants to respond or consult, they need to be able to reach you easily. Many medical offices still rely on fax for clinical correspondence. Include both phone and fax.

Ethical Considerations

Letters to primary care physicians involve straightforward but important ethical considerations related to consent, scope, and professional boundaries.

Informed consent is not optional. Even though HIPAA's TPO exception may permit sharing information with another treating provider without formal authorization, ethical practice requires that the client know what you are sharing and agree to it. Some clients may not want their PCP to know about certain aspects of their mental health — such as substance use, sexual health concerns, or specific diagnoses. Honor these preferences unless doing so would create a safety risk.

Scope of practice respect. Communication with PCPs works best when both providers respect each other's expertise. You bring specialized knowledge of the client's psychological presentation, treatment response, and behavioral observations. The PCP brings medical expertise, prescribing authority, and knowledge of the client's physical health. Frame your communication as sharing your expertise to support theirs, not as directing their medical care.

Confidentiality in medical records. Information you share with the PCP will become part of the client's medical record, which may be accessible to other providers, insurance companies, and — in some cases — employers or other entities. Consider the downstream implications of what you include and apply the minimum necessary standard.

Continuity of care responsibility. If you identify a clinical concern that affects the client's physical health — such as significant weight loss, severe insomnia, substance use, or medication side effects — you have a professional responsibility to ensure this information reaches the appropriate medical provider (with the client's consent). Failing to communicate clinically relevant information that you have reason to believe the PCP does not know can result in gaps in care that harm the client.

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