Therapists at Ruh Care may be asked to write a general mental health assessment or treatment verification letter for refugee clients, particularly those involved in legal proceedings such as asylum applications. These documents help convey a client’s emotional and psychological state and how continued stability and residence in Canada supports their healing and long-term wellbeing.

This guide outlines the steps, required documentation, and clinical considerations to ensure thorough, ethical, and client-centered reporting.

Canada Specific Guidelines

📌 Step 1: Determine the Type of Document

There are two types of documents you may be asked to provide:

General Letter Verifying Treatment:
- Confirms engagement in care and summarizes current mental health concerns.
Formal Intake Assessment:
- A more detailed clinical summary based on structured interview data and clinical impressions.

📝 Important: Ruh Care therapists do not provide formal psychological assessments. Please ask the client to confirm requirements with their lawyer and request a sample letter if possible.

📌 Step 2: Confirm the Recipient

Establish who the letter will be sent to:

Client (no extra paperwork needed)
Lawyer or Third Party (requires a Consent to Release and/or Obtain Information form — CCT will assign this via the portal)

📌 Step 3: Clarify Billing and Payment

If the lawyer is paying, they will typically require an invoice.
If the client is paying, this is billed as a session.
Scholarship clients are billed based on time invested, noted to the Clinical Manager.

Billing Rates:

30-minute letter/report writing = half session rate
60-minute letter/report writing = full session rate

📌 Step 4: Intake and Consent Process

When a letter is requested:

Therapist sends the “Letter Request” smart phrase via portal.
Client completes a form indicating:
- Purpose of the request
- Payor for additional charges
- Acknowledgement of data sharing disclaimers
CCT assigns a Consent to Release form if necessary.
CCT forwards the request to the Clinical Manager (CM), cc’ing the therapist.
CM confirms approval and provides access to Ruh letterhead.

📌 Step 5: Conducting the Interview — General Framework

Use this structure as a baseline for your clinical interview. You may include other standardized measures you’ve been trained in (e.g., Dissociative Experiences Scale (DES), Adverse Childhood Experiences (ACES)) where clinically appropriate.

📖 Suggested Data Points to Collect:

Demographic Information: Age, gender, country of origin, immigration status
Reason for Referral/Request
Presenting Concerns: Primary mental health symptoms (e.g., anxiety, depression, PTSD-related symptoms)
Trauma History: Brief overview of trauma experiences (if clinically appropriate and safe to disclose)
Migration and Settlement Experience: Barriers faced, current housing, employment, social support
Current Functioning: Emotional, social, and occupational/academic functioning
Protective Factors/Strengths: Community ties, religious faith, resilience strategies
Clinical Impressions: Symptom presentation, prognosis, and clinical recommendations

📌 Step 6: Writing the Letter or Assessment

In your letter, reflect the information gathered using Ruh’s letterhead. Ensure the document:

Is written in clear, non-technical language
Avoids diagnostic labels unless clinically necessary
May highlight how continued residence in Canada will support the client’s emotional wellbeing and safety

Include any validated measures administered (e.g., DES, ACES) and note scores if applicable.

📌 Step 7: Draft Review & Finalization

Share your semi-final draft with your Clinical Supervisor (if available) or the CM.
Incorporate suggested edits.
Upon approval, the CM will notify CCT to:
- Upload the finalized document to the client’s file
- Bill the payor as confirmed