The written word has always possessed a degree of permanence that the spoken word does not, even more so in our age of electronic communication. As therapists, we regularly employ the power of the spoken word, but sometimes feel anxious about sharing our impressions in writing, particularly when we don’t know who is on the receiving end.

Yet there are a variety of situations in which we might be asked to write letters on behalf of our patients, from ESA (Emotional Support Animal) letters to court subpoenas. These letters are a unique opportunity for patient advocacy but present ethical and legal challenges that verbal communications do not. Here are some things to consider when writing letters for your patients.

Types of letters

In addition to ESA letters, patients or outside agencies might request the following:

  • Disability accommodation letters
  • FMLA letters
  • Medical necessity letters (for insurance authorizations)
  • Letters for legal purposes
  • Letters of medical exception


Informed consent

Include your letter-writing policy in your informed consent, including any associated fees. Explain that outside communication will only occur with the patient’s explicit permission, and that information will be on a strictly “need to know” basis.

Before writing the letter, talk with your patient about what specifically will be included. If the situation allows, have your patient review the letter prior to submission.

Purpose of the letter

What objective do you and your patient hope to achieve with the letter?  Is the letter in your patient’s best interests given their current emotional state? Talk with your patient about the potential benefits and risks, including issues around privacy and confidentiality.

Legal considerations

In addition to confidentiality, there are legal considerations around the types of letters therapists are qualified to write. For example, in the case of ESA letters, some states now require therapists to have a long-standing relationship with the patient and complete a thorough assessment. (Incidentally, because the climate around ESA’s has become so fraught in recent years, the APA and ACA have issued position statements advising clinicians not to write ESA letters.)

Personal reservations and professional limitations

Even if your state gives you the green light, pay attention to your gut. Do you feel qualified to write the letter? If you are not comfortable with the request, why not? If it’s anxiety or inexperience, collaborating with a colleague might help. On the other hand, if it’s because of a conflict of interest or because you haven’t seen the patient in several years, you probably want to decline the request.

Be honest with yourself and your patient. If you don’t believe they qualify for a medical exception or would benefit from a specific accommodation, say so. The patient and the letter recipient will likely be able to sense your ambivalence in your writing.


Chances are, your letter-writing comfort level is at least partially determined by the prospective audience. Most therapists feel comfortable disclosing relevant information to other mental health practitioners, as they can be reasonably certain as to how the information will be received. However, in the case of court letters or letters for employers, you have no assurance that the recipient understands mental health or the therapy process. For this reason, the information you disclose should not extend beyond what is minimally necessary to achieve the purpose of the letter. In some cases, this may be limited to diagnosis and confirmation that the patient is in treatment with you.

What to disclose

In some cases, the requesting agency provides a detailed list of what your letter should include. For example, clinics that specialize in medical interventions for trans youth often ask for an assessment of the patient’s mental health, comorbidities, and psychosocial support. However, in most situations, you will need to use your clinical judgment as to what constitutes “need to know” information. For example, if the purpose of the letter is to help the patient procure academic or occupational accommodations, explain how these accommodations might help your patient to be successful at school or work. Make sure to frame any recommendations as your professional opinion; while we therapists understand that there are no guarantees when it comes to mental health, school officials and HR representatives may not.


Whenever possible, use documentation to support the information you disclose. This could include patient intake forms, standardized questionnaires, diagnostic summaries, or symptom checklists. Essentially, you want to be prepared in case the requesting agency asks you to substantiate your assessment and recommendations.


While writing letters on behalf of your patients may not land squarely in your professional comfort zone, it does provide a unique opportunity for patient advocacy. By keeping in mind the above guidelines, you can use your expertise to effectively support your patient while upholding ethical and legal obligations. If you still feel uncertain, consult with a colleague or seek the advice of a lawyer who specializes in mental health care. And remember, your clinical judgment will guide you as to what type of disclosures are necessary given the specific situation.

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