Most the time I address the letters/emails. The example here I did not. When I don't it's another clue as to where I am mentally and emotionally.

Lots of times it is Hi/Dear/good morning/afternoon.... Dr. lastname. I refer to her as Dr. LastName because she is a psychiatrist (DO). I believe she is open to going by either Dr. LastName or first name/preferred name. I know that with the clinical staff at the old location she went by a common abbreviation of her first name. I use the Dr. because it creates a level of separation and reminder that we are doc/patient and not something else. I have not actually asked her if she would mind or has a preference. She might prefer to remain Dr. LastName. I do from time to time think about her in first name and have in session referred to her as first name. Those times are always when I am speaking to the person behind the role and usually when I am afraid that I might have hurt her feelings... afraid something has affected her personally.