Date: ________________________ To: PHYSICIAN NAME: ______________________________________ FAX: __________________________

Mock Form Letter- for critique

From the Office of Chris Doe, PhD
720 Smith Rd., University, MN 55055 Phone: 555-555-1212 Fax: 555-555-1111

Psychotropic Medication Recommendation

Date: ________________________
To: PHYSICIAN NAME: ______________________________________ FAX: __________________________

CLIENT NAME: ______________________________________________ SSN: _________________________
CLIENT ADDRESS: ______________________________________ PHONE: ___________________________
PSYCHOTROPIC MEDICATION RECOMMENDATIONS:
Medication: ________________________________ Reason: ________________________________________
Medication: ________________________________ Reason: ________________________________________
Medication: ________________________________ Reason: ________________________________________
RECOMMENDED MEDICATION TO BEGIN: ______ Immediately _______ Next Visit
Please note that it is my opinion these medications are necessary. I have taken a course on prescribing medications. If you
have any questions or need any further information, please call me at 555-555-1212 or fax at 555- 555-1111.

OTHER COMMENTS:

1

John Doe, PhD, LLC, Clinical Psychologist
Psychotropic Medication Recommendation