Use this template when a client needs care beyond the therapy session
Referral and coordination of care notes document the steps you take when a client needs support from another provider, program, service, or member of their care team. This may include a referral to psychiatry, primary care, higher level of care, psychological testing, case management, substance use treatment, group therapy, or a community resource.
You may document this in a progress note, collateral contact note, case management note, treatment plan update, or separate care coordination entry, depending on your practice setting and documentation system. The goal is simple: record what was recommended, why it was clinically relevant, what the client agreed to, what information was shared, and what follow-up is planned.
Copyable referral and coordination of care template
Use this template as a starting point. Adjust the wording to match your documentation style, scope of practice, payer expectations, and record system.
Referral and Coordination of Care Note Template Date of contact/service: [Date] Client: [Client name or initials, depending on charting practice] Type of documentation: [Referral / care coordination / collateral contact / treatment plan update] Provider or service contacted/referred to: [Name, role, agency, specialty, contact information if appropriate] Reason for referral or coordination: [Briefly describe the clinical reason. Connect to symptoms, functional needs, treatment goals, safety concerns, medication needs, medical concerns, testing needs, or resource needs.] Client discussion and consent: [Document that the referral or coordination was discussed with the client. Include the client’s response, preferences, questions, and consent or limitations on information sharing.] Information shared or requested: [Document what information was shared or requested. Keep it specific and limited to the purpose of coordination.] Action taken by clinician: [Describe what you did: provided referral options, sent release of information, called provider, exchanged records, consulted with care team, helped client plan next steps, updated treatment plan.] Client response: [Document acceptance, hesitation, refusal, barriers, preferences, or follow-through plan.] Follow-up plan: [Document next steps, responsible party, expected timeframe, and how this will be reviewed in treatment.] Clinical relevance: [Briefly connect the referral or coordination to the client’s current treatment goals, risk needs, continuity of care, or symptom management.]
Completed example: referral to psychiatry for medication evaluation
The example below shows a practical entry for an outpatient therapy record. It is specific enough to support continuity of care without turning the note into a long narrative.
Referral and Coordination of Care Note Example Date of contact/service: 04/16/2026 Client: J.M. Type of documentation: Referral and care coordination Provider or service contacted/referred to: Psychiatric medication evaluation; client was provided three in-network psychiatry referral options and contact information. Reason for referral or coordination: Client reported ongoing depressive symptoms, including low motivation, disrupted sleep, reduced appetite, and difficulty completing daily responsibilities. Client stated that therapy has been helpful for identifying patterns and practicing coping skills but requested information about whether medication may be appropriate. Referral is related to treatment plan goal of reducing depressive symptoms and improving daily functioning. Client discussion and consent: Therapist discussed the purpose of a psychiatric medication evaluation, including that the psychiatrist or psychiatric prescriber would determine medication recommendations. Client expressed interest in referral and provided verbal consent to coordinate care once a provider is selected. Therapist reviewed need for a signed release of information before sharing clinical information with any outside provider. Information shared or requested: No outside clinical information was shared during session. Therapist provided client with referral options and discussed what information may be helpful to share after a release is completed, such as diagnosis, current symptoms, treatment goals, and therapy attendance. Action taken by clinician: Therapist provided referral list, encouraged client to contact providers before next session, and offered to coordinate care after client selects a provider and completes a release. Therapist updated treatment plan to include referral follow-through as a short-term objective. Client response: Client agreed with referral plan and stated preference for telehealth psychiatry if available. Client reported feeling “relieved to have options” and identified calling two providers this week as a manageable next step. Follow-up plan: Therapist will review referral progress at next session, assess barriers to scheduling, and coordinate with selected provider after signed release is obtained. Clinical relevance: Referral supports continuity of care and addresses persistent depressive symptoms that continue to affect sleep, appetite, motivation, and role functioning.
When to document a referral or care coordination contact
Document the referral or coordination activity whenever it affects the client’s treatment, safety, continuity of care, or treatment plan. A quick mention may be enough for a simple resource list. A more detailed entry is usually helpful when another provider becomes involved or when the referral is connected to clinical risk, medication, diagnosis, higher level of care, or major functional needs.
Common situations include:
- Referral to another clinical provider: psychiatry, primary care, psychological testing, substance use treatment, trauma specialty care, family therapy, or group therapy.
- Coordination with an existing provider: communication with a prescriber, school counselor, case manager, physician, probation officer, or hospital discharge planner.
- Higher level of care planning: referral to intensive outpatient treatment, partial hospitalization, residential care, detox, or crisis services when clinically indicated.
- Resource connection: housing support, food assistance, transportation, victim advocacy, employment support, or other community services related to treatment needs.
If the coordination is brief, the note can be brief. For example: “Client requested referral options for grief support group. Therapist provided three local and virtual options and will review follow-through next session.” The documentation should match the clinical significance of the action.
What to include in referral documentation
A strong referral note answers six basic questions: what was recommended, why it was recommended, what the client understood, what the client agreed to, what the clinician did, and what happens next. You do not need to write a long explanation if those points are clear.
Include these elements when they apply:
- Clinical reason: Link the referral to symptoms, treatment goals, functional impairment, safety planning, diagnostic clarification, or client request.
- Referral details: Name the provider, service type, agency, specialty, or category of referral, depending on what is known.
- Consent and information sharing: Record whether the client consented, declined, limited the release, or needs to complete a release form.
- Follow-up plan: Identify the next step, timeframe, and who is responsible for completing it.
Clear documentation protects the clinical story. It shows that the referral was not random; it was connected to the client’s needs and the active treatment plan.
What to include in coordination of care documentation
Coordination of care documentation focuses on communication and shared planning. The note should show who was involved, what was discussed, what decisions were made, and how the information affects ongoing treatment.
For example, if you speak with a psychiatric prescriber, your note might include the date of the call, the provider’s role, the topics discussed, the client’s consent status, medication-related information shared by the prescriber, and any therapy plan updates. If you participate in a school meeting, document the meeting purpose, attendees by role, relevant observations, and treatment-related follow-up.
Use neutral, behavior-based language. Instead of writing, “School was not helpful,” write, “Therapist participated in school meeting to discuss client’s increased absences and anxiety symptoms. School counselor reported client has missed 8 days this semester. Team discussed gradual return plan and client’s use of coping skills before first period.”
How referral notes fit into SOAP, DAP, and treatment plans
You do not always need a separate referral note. Many clinicians document referrals inside their usual progress note format. The key is placing the information where it makes clinical sense.
SOAP note placement
In a SOAP note, referral details often appear in the Assessment and Plan sections. The assessment can explain why the referral is clinically indicated. The plan can document the referral options provided, consent, and follow-up.
DAP note placement
In a DAP note, referral activity may appear in Data if it occurred during the session, in Assessment if it relates to clinical formulation, and in Plan for follow-up steps.
Treatment plan placement
If the referral changes the direction of care, update the treatment plan. This may include a new objective such as, “Client will complete psychiatric medication evaluation within 30 days,” or “Client will attend intake appointment for substance use assessment and discuss recommendations with therapist.”
Common mistakes that weaken referral and coordination notes
Most documentation problems come from missing context. The note may say that a referral was given, but not why. Or it may mention a call with another provider without identifying what was discussed or how it affects the client’s care.
- Writing “referred out” with no reason: Add the clinical need, such as medication evaluation, testing, medical concern, safety planning, or specialty treatment.
- Leaving out client response: Document whether the client accepted, declined, had concerns, requested alternatives, or needed support with follow-through.
- Sharing too much detail: Record the information needed for care coordination, not unrelated session content.
- Forgetting the follow-up plan: Include how and when the referral will be reviewed, especially if symptoms or risk concerns are active.
Another common issue is vague consent documentation. “Client gave permission” is less useful than, “Client signed release authorizing therapist to share diagnosis, attendance, treatment goals, and current symptom concerns with psychiatric provider.” Specific wording helps clarify the scope of coordination.
Practical documentation tips for therapists
Referral and coordination notes should be clinically useful first. If another provider, supervisor, auditor, or future version of you reads the chart, the note should make the next step clear.
Keep these habits in mind:
- Document promptly: Write the note soon after the session, call, email, or meeting while details are still accurate.
- Use the client’s words when helpful: A short quote can clarify motivation, hesitation, or preference.
- Connect to the treatment plan: Show how the referral supports goals, symptoms, risk reduction, or functioning.
- Separate facts from impressions: Document what was reported, observed, recommended, and planned.
Concise notes can still be strong. A focused paragraph often works better than a long entry filled with repeated history. For example: “Therapist provided referral to primary care due to client’s report of persistent insomnia, fatigue, and no medical evaluation in the past year. Client agreed to schedule appointment and signed release for coordination if medical concerns affect treatment planning.”
Privacy and consent language to document clearly
Before coordinating with another provider, document the client’s permission and the scope of what may be shared. Requirements vary by setting, payer, and jurisdiction, so use your organization’s forms and policies. In daily practice, the note should still answer a practical question: what did the client allow you to share, with whom, and for what purpose?
Examples of clear consent language include:
- “Client signed release authorizing coordination with primary care provider regarding sleep concerns, medication list, and treatment planning.”
- “Client declined release for family contact at this time. Therapist will revisit if client requests family involvement.”
- “Client provided consent to send attendance confirmation and treatment goals to case manager; therapist did not share detailed session content.”
- “Client requested referral options only and did not authorize therapist to contact outside providers today.”
This wording keeps the note specific without becoming a legal policy document. It also helps clinicians avoid accidental over-sharing when coordinating care across systems.
How AutoNotes helps create editable referral and coordination drafts
AutoNotes helps behavioral health professionals turn session details into structured, editable documentation drafts. For referral and coordination notes, that means you can start with the key clinical facts—reason for referral, client response, consent status, action taken, and follow-up plan—then generate a draft that is organized around the type of service you provided.
Unlike a generic writing tool, AutoNotes is built for behavioral health documentation workflows. Clinicians can create drafts for progress notes, intake sessions, assessments, treatment planning, group therapy, and other common services. Referral and coordination details can be included in the plan section of a SOAP or DAP note, added to a care coordination note, or reflected in treatment plan updates.
The clinician remains responsible for review. AutoNotes gives you a structured draft, not a final clinical judgment. You can edit the language, add missing details, remove anything inaccurate, and make sure the note reflects the actual service provided.
This is especially helpful after a full day of sessions, when referral details are easy to under-document. A consistent prompt can remind you to include the provider referred to, the reason, the client’s response, consent status, and follow-up plan.
Start with a cleaner referral note today
If referral and coordination documentation is taking too long, start by using the template above for your next applicable session. Keep the note specific, tie the referral to the treatment plan, document consent clearly, and include the next step.
AutoNotes can help you create structured, editable drafts faster while keeping you in control of the final note. Start your free trial and try it with your next referral, care coordination contact, or treatment plan update.
