Sample Letter For Medical Evidence Of Domestic Violence printable pdf download

Response from health professional to request for

evidence of injuries/condition consistent with domestic

violence

This example letter has been designed by the Ministry of Justice to be used by

doctors (including GPs), nurses, midwives, practitioner psychologists & health visitors

(or, in the examining health professional’s absence, another health professional who

has access to the applicant’s medical records), when responding to requests for

evidence of injuries or condition consistent with domestic violence.

Information required is highlighted and instructions are italicised. Please delete any

unnecessary text and instructions (including this introduction) before sending.

HEADED LETTER [Please can you ensure that the letter is on headed paper from

the surgery or hospital where the doctor, nurse, practitioner psychologist, health

visitor or midwife practises.]

[Addressee name]

[Your Address]

[Address]

[Your E-mail (if applicable)]

[Your Contact telephone number]

[GMC/NMC/HCPC] Registration Number:

[GMC/NMC/HCPC] Registration Number]

Dear [Insert name of addressee],

Name of applicant: [Name of applicant]

I understand that [APPLICANT’S NAME] (‘the Applicant’) wishes to access legal aid

for a family dispute as a victim of domestic violence. For this reason I have been

asked to provide a letter in accordance with regulation 33 of the Civil Legal Aid

(Procedure) Regulations 2012.

Accordingly I can confirm that the Applicant presented [himself/herself] to me [insert

relevant health professional’s name] on the [DATE WHEN CONSULTATION

OCCURRED] (being within 5 years prior to the Applicant’s intended application for

legal aid). After examining them I [insert relevant health professional’s name] was

satisfied that the [injuries [and/or] condition] that the Applicant presented me [insert

relevant health professional’s name] were consistent with domestic violence.

I understand that the Ministry of Justice and the Legal Aid Agency recognise that the

great majority of physical injuries and many non-physical conditions could be caused

by domestic violence.

I understand that this evidence is only required for a decision on whether or not to

grant legal aid – it is not designed to prove domestic violence in the context of a

criminal or civil court case.

LA.DV.Med.ER_0413

Sample Letter For Medical Evidence Of Domestic Violence