To a potential patient

I am a psychiatrist who provides medication treatment for patients who also see therapists for mental health care. You have been referred to me by your therapist (psychologist, social worker, or psychotherapist) for assistance in your care. You will continue to work with your therapist, who will be the person primarily responsible for your overall treatment. I will manage your medications. If you have a problem related to your care and are unsure whom to call, call your therapist first. 

Once you have read this page, please ask your therapist any questions you have of him/her about how the three of us will work together. When we meet, please ask me to answer any additional questions that have occurred to you. 

I do not supervise your therapist, but I do collaborate with him/her to ensure that your treatment works for you. The bottom part of this letter is a release form that allows me to communicate with your therapist. Please sign this form to acknowledge that you know your therapist and I will collaborate in your care. We will give you a copy of the form for your files.

Sincerely, ____________________________________________________________
                                (psychiatrist’s name)


I, ________________________________________, hereby acknowledge and give my


permission to my therapist, _______________________________________, and my

psychiatrist, ________________________________________, to communicate with

one another about my mental health treatment to better meet my needs. I have asked

my therapist and my psychiatrist all the questions I have about this collaboration and 

they have answered my questions to my satisfaction. This form will be in effect while I am Dr. 

________________________’s patient, or unless I revoke my consent in writing.
    (Psychiatrist’s name)

Signature _______________________ Date _______________ 
                (Patient’s name)

Witness _________________________ Date _______________ 

Figure 2