Therapy Diagnosis Letter You Can Adapt

A client asks for a letter before the next appointment. The request is simple: confirm a diagnosis, or confirm that the client is under your care. The risk is saying more than the chart supports. This letter of diagnosis template keeps the response narrow.

Use the short letter above as a drafting aid. Replace every bracket, confirm the recipient and purpose, check the release-of-information path, and sign only after you have reviewed the final wording against the chart.

Educational drafting aid for licensed US mental-health clinicians. This template is not legal, billing, licensure, or diagnostic advice. Apply the requirements that govern your license, setting, payer, client, and recipient before you send a letter.

Start with the recipient and purpose

A letter of diagnosis is not a portable copy of the chart. First write down who requested it, who will receive it, and what decision the recipient needs to make. That gives you a reason to include one fact and a reason to leave another fact out. Keep this letter of diagnosis tied to that purpose.

A request for a school, employer, insurer, court, housing provider, or another clinician can call for different information and a different release process. Do not guess what the recipient wants. Ask for the exact purpose and requested wording in writing, then use the narrowest statement that answers that purpose.

If the request is really for a service or item to be covered, use the letter of medical necessity for therapy resource instead. If the request is about claims, eligibility, or authorization, use insurance billing for therapy.

What the chart can support

Before you draft, open the chart and check the source for each sentence. A useful review asks:

• Is the client identified correctly under your approved practice workflow?
• Is the diagnosis documented in the current record you are authorized to use?
• Are the dates of care accurate?
• Does the letter distinguish a diagnosis from a symptom, screening result, or rule-out consideration?
• Is every sentence relevant to the stated recipient and purpose?
• Does the chart support the level of certainty used in the sentence?

If the chart supports that a client is under your care but does not support a particular diagnosis, write the under-care letter. If the diagnosis is documented but the request only needs confirmation of care, do not add the diagnosis just because you have it.

A diagnosis letter is also not a substitute for a diagnostic evaluation. Do not use a short confirmation letter to make a new diagnosis, predict work or school performance, certify a disability, or answer a question outside the evaluation and documentation you actually completed.

Release-of-information check

Before sending protected health information, confirm the permission and delivery path that apply to the request. Under 45 CFR 164.506, a covered entity may use or disclose protected health information for treatment, payment, or health care operations in defined circumstances, subject to other applicable requirements and authorization exceptions. Review the rule and any other requirements that apply to your setting.

A practical check:

1. Confirm the recipient’s name and contact information.
2. Confirm the purpose in the request.
3. Identify whether the client’s written authorization is required for this disclosure.
4. Check that the authorization identifies the information, recipient, purpose, and expiration or other required elements when applicable, as described in 45 CFR 164.508.
5. Send through an approved secure method and record what was sent, to whom, when, and under what permission.

Do not paste an authorization into the letter unless the recipient needs it. Store the authorization and transmission record according to your practice policy.

Statements to include and statements to withhold

The safest letter is not the longest one. Use the table as a drafting boundary, then apply the rule for your setting.

Include when supported	Withhold from this short letter
The narrow purpose and recipient	Psychotherapy notes or session-by-session narrative
Confirmation of a documented diagnosis, if the purpose requires it	Speculation about cause, prognosis, or future behavior
Confirmation that the client is under your care	Unrelated diagnoses, history, or family information
Dates of care that the chart supports	A new diagnosis made only for the letter
The minimum functional or administrative fact the recipient needs	Claims about what another person did or believes
Your name, credentials, contact, and signature	A guarantee that a payer, school, employer, court, or other recipient will approve a request

“Limited to what the chart supports” does not mean copying every fact in the chart. It means the selected facts must be accurate, relevant, and stated with the certainty the record supports.

Diagnosis wording versus under-care wording

Use one of these two paths rather than blending them:

Diagnosis confirmation. Name the diagnosis documented in the chart and, when needed for the purpose, the applicable code. Do not add a code from memory or infer one from a symptom list. Confirm the code and wording in your approved coding reference before signing.

Under-care confirmation. State that the client is under your care, name the dates the chart supports, and state the limited purpose. If the recipient does not need the diagnosis, leave it out.

Both paths need a signature block. A typed name may not satisfy every workflow, payer, court, or organization requirement, so follow the signature policy that governs the document.

A five-minute pre-send review

Read the letter once as the clinician and once as the recipient.

• The client and recipient are identified without an avoidable mismatch.
• The purpose is specific.
• The diagnosis or under-care statement is supported by the chart.
• Dates, credentials, contact information, and signature are complete.
• The release-of-information path is documented.
• The delivery method is approved and the transmission is recorded.
• No psychotherapy notes, unrelated history, speculation, or guarantee slipped in.

If the recipient asks for more than the chart supports, pause. Ask what decision the additional information is meant to support, consult the rule or policy that governs the request, and document the response rather than improvising a broader letter.

Keep this letter separate from other documents

A letter of medical necessity for therapy explains why a specified service or item is needed. A therapy termination letter communicates an ending and continuity steps. A diagnosis or under-care letter confirms a narrow fact for a stated purpose. Keeping those documents separate helps you avoid sending a diagnosis letter when the recipient actually needs a different record or explanation.

Sources and scope

• Electronic Code of Federal Regulations: 45 CFR 164.506
• Electronic Code of Federal Regulations: 45 CFR 164.508

These links are starting points, not a substitute for the rules, contracts, policies, and professional guidance that govern a particular request. Review the current source and your local requirements before sending.