James Fitzgerald Therapy PLLC

The initial screening process aims to ensure a comprehensive assessment of the client, including ruling out nonpsychiatric medical and substance-induced etiologies that may contribute to or exacerbate their psychological symptoms. This step is critical in creating an effective and accurate treatment plan.

During the assessment process, if it is suspected that your symptoms might be due to an underlying medical problem, I will encourage you to arrange, cooperate with, and complete, a medical evaluation by a licensed medical professional. I will help you arrange for a medical evaluation to rule out nonpsychiatric medical and substance‐induced etiologies (e.g., hyperthyroidism, stimulant use).

Arranging a Medical Evaluation:

I will explain the importance of a medical evaluation, emphasizing that it is a standard procedure to ensure that your symptoms are not caused by underlying medical conditions or substance use. I will obtain your informed consent for coordinating the medical evaluation and any necessary sharing of information between healthcare providers.

I will then gather the relevant initial information, review your clinical and medical history, including any known medical conditions, current medications, and any recent changes in your physical health. I will make note of any symptoms that could be indicative of medical issues, such as unexplained weight loss, fatigue, dizziness, or chronic pain.

If you don’t already have a primary care provider, I will help you select a healthcare provider. I will identify a suitable primary care physician or specialist (e.g., an internist or endocrinologist) based on your specific needs and any existing healthcare relationships. If substance use is identified as a problem, we should consider referring to an addiction specialist or a facility that offers comprehensive substance use evaluations.

If you request it, I will assist you in scheduling an appointment with the chosen healthcare provider, ensuring the appointment is timely to avoid delays in the treatment plan. I will provide you with any necessary documentation or referral letters detailing the purpose of the medical evaluation and specific areas of concern.

Preparing the Referral Documentation:

If needed, I will prepare a detailed referral letter. I will provide only the following information:

• Personal information and contact details.
• A brief summary of the presenting psychological symptoms.
• Relevant medical history and current medications.
• Specific concerns or symptoms that warrant a medical evaluation.
• Contact information for the referring therapist or counseling practice.

Instructions for Making a Referral:

Identifying Appropriate Referral Resources: I will provide you with a list of trusted healthcare providers, specialists, and facilities that can conduct comprehensive medical evaluations. It is your responsibility to verify that the referral resources are covered by your insurance plan, if applicable.

Please note: I am not employed by or affiliated in any way with any hospital, clinic, group practice, government department, or designated mental health care agency.

Providing Client Support: I will offer to help you navigate the referral process, including providing transportation assistance if needed. Please ask questions and voice any concerns you may have about the referral or evaluation process.

Facilitating Communication: With your consent, I will establish communication between me and your healthcare provider to ensure a coordinated approach. I will provide the healthcare provider with relevant background information and any specific questions or concerns that need to be addressed during the medical evaluation.

Follow-Up: I will schedule a follow-up session with you to discuss the outcomes of the medical evaluation. I will incorporate any findings from the medical evaluation into your treatment plan, adjusting therapeutic interventions as necessary.

Documentation:

I will document all steps taken in the referral process, including copies of referral letters, client consent forms, and notes from any communication with healthcare providers. I will maintain detailed records of your medical evaluation results and any subsequent changes to the treatment plan.

Conclusion By systematically arranging a medical evaluation and making appropriate referrals, therapists can ensure that their clients receive a holistic assessment that considers both psychological and physical health factors. This integrated approach enhances the accuracy and effectiveness of the treatment plan, ultimately supporting better outcomes for the client.