Download Request for Therapist Letter of Support

Mailing Address:
Division of Gastrointestinal & Bariatric Surgery
420 Delaware Street SE, MMC 195
Minneapolis, MN 55455
Office: 612-626-6666
Fax: 612-625-3206
Dear Psychiatrist/Psychologist/Therapist:
We have a mutual patient with morbid obesity who is considering undergoing bariatric
surgery. A psychological evaluation is being done to see if this patient is cleared from a
psychological perspective to undergo the elective surgery. However, we need your
assistance with a letter of support as outlined below. Your input is valuable and will
affect our decision to hold or proceed with bariatric surgery.
This letter of support should outline:
1.
Summary of treatment to date.
2.
Treatment goals for before and after surgery that indicate mental health support
and continuation of care.
3.
Any concerns regarding this patient’s ability to follow through with treatment
recommendations.
4.
If known, documentation of cessation of illicit drug use (our policy requires
patients to be drug free of illicit drugs for at least one year prior to surgery).
5.
A statement that indicates if you support or do not support this patient for weight
loss surgery.
Please fax the letter of support to 612-625-3206, attn: Barbara
If any questions, feel free to call Barbara Sampson, RN at 612-625-1124 or page her at
612-899-1106.
Sincerely,
Dr. Sayeed Ikramuddin; Dr Daniel Leslie; Kristi Kopacz, PA-C
Weight Loss Surgery Center
University of Minnesota HEALTH
www.umnwls.org