ESA Letter Template Preview

                    [Licensed Mental Health Professional Letterhead]

                    Date: [MM/DD/YYYY]  
                    [Recipient's Name/Address]  
                    
                    To Whom It May Concern,
                    I, [Full Name of Licensed Professional], [License Type and Number], hereby certify that:
                    1. Patient Information:
                       - Name: [Patient's Full Name]
                       - DOB: [Date of Birth]
                       - Diagnosis: [ICD-10 Code: FXX.X - Brief Description]
                    2. Treatment Relationship:
                       - Actively under my care since [MM/YYYY]
                       - Last consultation: [MM/DD/YYYY]
                       ......