You know the nuts and bolts you need to include — now, how do you pull it all together? It may feel easier if you break it down into smaller steps.
Start by gathering all of the information you need, including your client’s diagnosis, treatment history, and any forms or instructions from the requesting institution. It’s easier to have all of that handy now, rather than searching while you’re writing.
As you work through the sections below, focus on using clear, professional, and precise language. While you’ll include medical terminology (like DSM-5-TR codes) where it’s relevant, avoid overly technical jargon that could confuse reviewers.
Step 1: Craft a strong opening statement
You don’t need to get too creative here. Remember, this is medical documentation — not a novel or an emotional plea. So, begin your letter with a concise and straightforward introduction that states your professional credentials and establishes your relationship with the client.
Example: “I am a licensed clinical social worker (LCSW) with ten years of experience providing therapy to adults. I have been treating Jane Doe weekly for the past two years for symptoms related to generalized anxiety disorder (GAD).”
Step 2: Document diagnosis and treatment history
Explain the diagnosis (including relevant DSM-5-TR codes, if appropriate) and the onset or duration of symptoms. You’ll also briefly summarize the treatment approaches you’ve used. Sticking with a general overview of the treatment modality helps the recipient understand the clinical context, while still being mindful of your client’s privacy.
Example: “Jane meets the diagnostic criteria for generalized anxiety disorder (DSM-5-TR code 300.02) and has participated in weekly cognitive behavioral therapy sessions since her diagnosis in October 2023.”
Step 3: Describe functional limitations and needed accommodations
The recipient of this letter isn’t a clinician, so they need more explanation beyond the diagnosis. In this section, you’ll give the context they need by clearly explaining how the client’s condition affects their daily functioning. Stay focused on observable impacts and connect these to your recommended accommodations.
Example: “Jane experiences increased stress in busy office environments, which can make concentrating and managing multiple tasks difficult. A remote work arrangement would provide a calmer environment that supports her focus and productivity.”