The Client Moved: Telehealth, Licensure, and a Request for a Letter

The governing principle: for telehealth, the client's physical location at the time of service defines where the practice occurs. Renee is now in another state, so that state's licensure requirements apply to sessions 10 onward, regardless of where I sit.

What I must verify before the next appointment: (1) whether the new state requires a full license, offers a temporary practice provision for continuity of care, or has a telehealth registration pathway; (2) whether my home-state board permits me to continue with an established client across lines; (3) whether my malpractice carrier's coverage matches what I conclude; (4) whether the client's insurance plan will reimburse a provider licensed elsewhere. These are checkable facts, and I check them rather than reason from assumption - state rules differ substantially and change.

The decision tree: if the new state permits practice under a temporary or telehealth provision, I continue, and I document the rule I relied on and the date I verified it. If it does not, I cannot continue clinical services, and no amount of clinical need changes that. Clinical need does change what I do next: it makes the handoff urgent and makes an abrupt stop a potential abandonment problem.

What I do not do: continue "just until she finds someone" without authority, rationalize it because the treatment is going well, or describe the sessions as "consultation" to sidestep the licensure question. That is a mischaracterization, and it is exactly what boards sanction.

Same-day actions: call the new state's board or check its website, consult my own board and, if ambiguous, an attorney or my professional liability hotline, and tell Renee honestly what I am doing and when she will hear back - silence while I investigate is what she will experience as abandonment.

Frame it accurately. Renee is not being discharged for improving and not being abandoned for moving. The constraint is jurisdictional, and I say so plainly in the session rather than in an email: "I can't legally be your therapist while you're in that state. That's a rule about where I'm allowed to practice, not a decision about you."

Bridge only what is permitted. If the new state allows a limited number of transition sessions under a temporary provision, I use them structurally: three sessions, each with an agenda - a written relapse-prevention plan for panic, a local resource list, and an introduction to the next provider. If no provision exists, I do not schedule further clinical sessions at all.

The clinical risk to address now. Two nocturnal panic attacks after a move, living alone, no local supports. The plan includes interoceptive and cognitive skills she already has and has used successfully, a written step-by-step for a night panic, a primary care contact in the new state, and the 988 line. Her improvement is a protective factor, and I name it so the transition does not read as "I'm too sick to be left."

Referrals that are real. Not a generic list: I confirm which local providers are accepting new clients and take her insurance, and I offer a release so I can speak with the next therapist directly. A fifteen-minute professional-to-professional call does more for continuity than a page of names.

Records and closure. I provide a treatment summary with release, explain how to request records, and document the licensure determination, the date and source of the verification, the referrals provided, and the client's response.

The licensure problem and the letter are separable. A letter documenting treatment I actually provided, and my clinical opinion formed during that treatment, is not the unlicensed practice of psychology in her new state. What I cannot do is base the letter on sessions that occurred where I was not authorized to practice.

Before writing it, I ask what the letter is for - an employer, a leave request, or a formal accommodation process - because the audience determines the content and the level of detail her privacy can tolerate. I obtain a written release specifying to whom the letter goes and what may be disclosed. I explain that I will describe diagnosis and functional limitations, not her history, and that an employer who receives it will know she is in treatment.

What the letter contains: the diagnosis (panic disorder), the date treatment began and its course, the observed functional limitations (panic attacks occurring in enclosed or crowded spaces, difficulty with sustained concentration during a panic episode), and the clinical rationale for the specific accommodations she requested - a quiet workspace and permission to step away briefly. It states what I can support, not what an attorney or HR department should conclude. I do not opine on disability status or legal entitlement; I describe the clinical picture and let the process do its work.

What I do not do: write a letter retroactively covering the post-move period, overstate severity to strengthen her request, or promise accommodation outcomes. Honest letters are also durable letters - if the employer questions it, the file must support every sentence.

Documentation: the release, the request, the letter as sent, and a note that the letter concerns services delivered while I was authorized to practice.