Contents of the Template
This template includes:
- Healthcare Professional’s Information: A section dedicated to the detailed contact and licensing information of the healthcare professional issuing the letter.
- Patient Information: A structured table for all the necessary patient details, including full name, date of birth, address, and contact information.
- Diagnosis Codes and Descriptions: Space for listing the patient’s diagnosis, utilizing DSM-5/ICD-10 codes and detailed descriptions.
- Treatment History: A section where the healthcare professional can outline previous and current treatments the patient has undergone.
- Clinical Justification for Psychiatric Service Dog: A dedicated section for explaining why a Psychiatric Service Dog is necessary for the patient, including specific tasks the dog will assist with.
- Duration for Which PSD is Required: Options to specify whether the PSD is recommended for short-term or long-term use, with room for additional explanation.
- Follow-up and Reevaluation Plan: A segment where healthcare professionals can outline their plans for patient follow-up.
- Disclaimer and Signature: A section for the healthcare professional’s signature, certifying the truth and accuracy of the letter, and a disclaimer acknowledging the professional’s understanding of the responsibilities associated with recommending a PSD.
- License Verification Information: Details for verifying the healthcare professional’s license.
- Enclosures: A section to list any additional documents enclosed with the letter.
Why Use This Template
- Clarity and Organization: This template is designed to guide healthcare professionals in clearly and effectively stating the patient’s need for a PSD.
- Accessibility: Available in Word, PDF, and Google Docs formats for easy use and customization.
- Conformity with Standards: The template is structured to include commonly required information, making it easier for healthcare professionals to provide necessary details.
- Time Efficiency: Using this template can significantly reduce the time spent on drafting a letter from scratch, as it includes organized sections and prompts for relevant information.
Ideal For
- Licensed Healthcare Professionals: Such as psychiatrists, psychologists, and clinical social workers who are treating patients with mental health disorders.
- Patients Needing Accommodation Support: For those requiring documentation to support a request for a PSD as a reasonable accommodation in housing or during travel.
- Legal and Disability Advocates: Assisting individuals in navigating the processes for requesting accommodations due to a mental health condition.
